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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850025
Report Date: 07/11/2022
Date Signed: 07/11/2022 01:56:16 PM


Document Has Been Signed on 07/11/2022 01:56 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:SANTA MARIA TERRACEFACILITY NUMBER:
425850025
ADMINISTRATOR:ENRIQUEZ, SANJUANAFACILITY TYPE:
740
ADDRESS:1405 E MAIN STTELEPHONE:
(805) 925-8713
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY:140CENSUS: 97DATE:
07/11/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Amy Bowman, Wellness DirectorTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Olson conducted an unannounced case management visit to issue a deficiency. LPA Olson received multiple Incident Reports (IR) from the facility that were sent after the required 7-day time frame. LPA provided courtesy reminder emails to the Administrator on 3/30/2022, and to the Administrator and Wellness Director on 5/27/2022. LPA continued to receive Incident Reports late, including:

· On 6/7/2022, LPA received IRs from 5/22/2022 (16 days after incident), and from 5/18/2022 (14 days after incident).

· On 6/23/2022, LPA received IRs from 6/15/2022 (8 days after incident), 6/14/2022 (9 days after incident), 6/13/2022 (10 days after incident).

· On 6/29/2022 LPA received IRs from 6/19/2022 (10 days after incident), 6/18/2022 (9 days after incident) and 6/17/2022 (8 days after incident).

Based on the information obtained, the facility is cited for late reporting.

Exit interview, report given, deficiency cited on 809-D, appeal rights given.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/11/2022 01:56 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: SANTA MARIA TERRACE
FACILITY NUMBER: 425850025

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/15/2022
Section Cited

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87211(a)(1) Reporting Requirements. A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below...
This requirement was not met as evidenced by:
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Based on record review, the licensee did not ensure incident reports were sent within 7 days of the occurrence on multiple occasions, which posed a potential health, safety, and personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2022
LIC809 (FAS) - (06/04)
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