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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850025
Report Date: 09/07/2023
Date Signed: 09/07/2023 05:25:53 PM


Document Has Been Signed on 09/07/2023 05:25 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: 94DATE:
09/07/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Joanna Enriquez, AdministratorTIME COMPLETED:
05:45 PM
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Licensing Program Analyst (LPA) Jenny Olson arrived at the facility unannounced to conduct an annual continuation visit at 9:45 a.m. LPA met with Administrator and informed them of the reason for the visit.

LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The facility has four stories, 123 assisted living units. LPA toured building's main lobby, 12 resident rooms, dining room, kitchen, TV room, library, activities room, 2 stairwells, and garden.

KITCHEN: LPA toured the kitchen around 10:00am. Kitchen appliances were clean and in operable condition. The facility has a sufficient supply of perishable and non-perishable food as well as emergency food and water.

Common areas: All furniture was observed to be in good condition. Carbon monoxide detectors were tested and operational at the time of the visit. LPA observed required postings throughout the common spaces. The fire extinguishers were charged and serviced on 9/9/2022. The fireplace in the TV room is screened and inaccessible.
Outdoor areas had umbrellas and other covered outdoor area equipped with furniture for resident use. Washer and dryers were functioning and in operable condition.

Restrooms: Resident rooms had private restrooms which were clean and sanitary and in operating condition with non-skid mats/strips. All resident and public bathrooms were sufficiently stocked with soap and paper towels.

Continued on 809-C
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2023
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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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
VISIT DATE: 09/07/2023
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INFECTION CONTROL: The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. The facility’s policies and procedures as it pertains to infection control are adequate.
Exit interview conducted. A copy of the report was provided.

The last disaster drill was conducted on 8/31/2023.

Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023
LIC809 (FAS) - (06/04)
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