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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850025
Report Date: 02/02/2024
Date Signed: 02/02/2024 04:35:06 PM


Document Has Been Signed on 02/02/2024 04:35 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: 95DATE:
02/02/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Vanessa Vazquez, Wellness CoordinatorTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Olson conducted a Case Management - Incident visit to issue deficiencies on a medication error the facility self reported. LPA met with Administrator and Wellness Director over the phone and explained the purpose of the visit.

CCL received an incident report on 01/27/24 stating that on 01/21/24 Staff 1 (S1) prepared 2 different medications at the same time and took the wrong one to Resident 1 (R1). R1 was given medications that could decrease respirations, resident was informed and the doctor was called immediately. R1 was given the option to go to the ER but they declined so care staff monitored R1 in their room, one-to-one for respiratory depression until 4am and then twice per shift from 1/22/24 through 1/24/24. Staff 1 was written up and retrained on the 7 resident rights by Wellness Director.

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

A civil penalty for a repeat violation for $250 was assessed.

An exit interview was conducted, a copy of the report, Civil Penalty, and appeal rights were issued.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2024
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 02/02/2024 04:35 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: 02/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/02/2024
Section Cited
CCR
87465(a)(4)

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87465 Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility... (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:
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From 1/24/23-1/26/24 Facility conducted an in service training for all med techs on the importance of live passing medications and Wellness Director met with each med tech individually for a knowledge check on live pass. POC was completed at the time of the visit.
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Based on interviews, the licensee did not comply in the section sited above when staff did not properly assist residents with medications and issued the incorrect dose which posed an immediate health and safety 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: 02/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2024
LIC809 (FAS) - (06/04)
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