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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850025
Report Date: 08/31/2021
Date Signed: 08/31/2021 03:59:04 PM

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: 85DATE:
08/31/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Sanjuana Enriquez, AdministratorTIME COMPLETED:
02:50 PM
NARRATIVE
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On 8/31/21 at 11:30 AM, Licensing Program Analyst (LPA) Toan Luong contacted Administrator Sanjuana Enriquez to perform a facility risk assessment. LPA conducted an unannounced on-site One Year Infectious Control Annual visit to the facility. LPA met with Administrator Sanjuana Enriquez and explained the purpose of the visit.

Administrator took LPA on a physical plant tour of the facility. The facility has submitted a mitigation plan to the department.

The facility is a Residential Care Facility for the Elderly. During the facility tour, LPA advised posting signs of CDSS PINs and have PINs readily accessible to residents, visitors, and staff. LPA advised Administrator to have Emergency Disaster Plan contact numbers readily available for staff and residents as it was posted in a frame behind page 1 of LIC 610E. Administrator posted CDSS PINs and displayed contact information from LIC 610E prior to LPA's departure.

LPA reviewed the Annual Mitigation Inspection Control Tool Module. Module was addressed with Administrator to satisfaction.

LPA reviewed staff roster and noted an individual was working without CDSS clearance. LPA issued an immediate citation.

Exit interview was conducted. No other deficiencies were cited. Report and appeal rights emailed to Administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Toan LuongTELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021
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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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: 08/31/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(g)(1)


This requirement is not met as evidenced by: LPA reviewed Guardian and LIS roster and discovered individual has an inactive status. Fingerprints
Deficient Practice Statement
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Based on record review and observation of the individual being present at the facility, the licensee did not comply with the section cited above in 1 count, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/01/2021
Plan of Correction
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Facility will remove individual from the roster while the individual completes LIC 9163 Request for Live Scan Services.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Toan LuongTELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2021
LIC809 (FAS) - (06/04)
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