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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850025
Report Date: 01/19/2023
Date Signed: 01/19/2023 04:55:52 PM


Document Has Been Signed on 01/19/2023 04:55 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: DATE:
01/19/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Joanna Enriquez, AdministratorTIME COMPLETED:
05:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Olson conducted an unannounced Case Management- Deficiencies visit to ensure the quality of care provided based on facility had a COVID-19 outbreak and was told multiple times to report cases timely and submit incident reports. During today’s visit, LPA Olson met with Joanna Enriquez, Administrator and explained the reason for the visit.

On 12/27/22 Administrator informed LPA Olson that multiple residents and a staff have tested positive for COVID. LPA Olson asked by email for the required information on 12/28/22 and again by email on 12/30/22. Administrator didn’t send required information to LPA until 01/02/23. On 01/03/23 LPA Olson emailed Administrator and Wellness Director that Incident Reports were due that day to be considered on time per regulation (87211). The facility didn’t send the resident incident reports until 01/09/23 (6 days late) and Staff Incident reports were received on 01/16/23 (13 days late).

On 01/09/23 LPA Olson sent an email to Wellness Director and Administrator stating again they didn’t follow reporting requirements after receiving another incident report stating a new resident tested positive for COVID on 01/04/23. On 1/18/22 CCL received another incident report stating a new resident tested positive for COVID on 1/10/22 which is both a late incident report (1 day late) and late COVID reporting (7 days late).

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

A $250 Civil Penalty for a repeat violation was issued.

Exit interview conducted, copy of report, civil penalty and appeal rights were emailed to Administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2023
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 01/19/2023 04:55 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: 01/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/26/2023
Section Cited

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87211(a)(1)(D) Reporting Requirements (a) Each licensee shall furnish... the following: (1)A written report shall be submitted to the licensing agency...within seven days of the occurrence of any of the events specified in (A) through (D) below....
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Administrator agreed to submit a plan to ensure written reports will be submitted to CCL within 7 days and submit plan to LPA by 1/26/23.
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This requirment was not met as evidenced by: Based on record review, the licensee did not comply with the section cited above when the facility did not submit a written report within 7 days, which poses a potential health, safety or personal rights risk to persons in care.
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Type B
01/26/2023
Section Cited

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87211(a)(2) Reporting Requirements
(a) Each licensee shall furnish....reports ...(2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents...within 24 hours either by telephone or fax...
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Administrator agreed to submit a plan to ensure occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents will be reported to CCL within 24 hours and submit plan to LPA by 1/26/23
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This requirment was not met as evidenced by: Based on record review, the licensee did not comply with the section cited above when the facility did not report an epidemic outbreak within 24 hours, which poses a potential health, safety or personal rights risk to persons 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: 01/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2