425850025-9-6-2023-29-AS-JOLN-CVEVKW-20230906163100

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425850025
Report Date: 09/06/2023
Date Signed: 09/06/2023 04:32:10 PM

Document Has Been Signed on 09/06/2023 04:32 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 TERRACE		FACILITY NUMBER:	425850025
ADMINISTRATOR:	ENRIQUEZ, SANJUANA		FACILITY TYPE:	740
ADDRESS:	1405 E MAIN ST		TELEPHONE:	(805) 925-8713
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93454
CAPACITY:	140	CENSUS: 94	DATE:	09/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Joanna Enriquez, Administrator		TIME COMPLETED:	04:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Jenny Olson arrived at the facility unannounced to conduct a required annual visit at 9:30 a.m. LPA met with Administrator and informed them of the reason for the visit. Records: LPA reviewed resident and staff records. LPA reviewed five (5) resident files for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, and current needs and services plan. All files were complete. LPA reviewed five (5) staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, current first aid certification. All files were complete. MEDICATIONS: Medications review began around 1:30 p.m. The medications are centrally stored and locked in a med cart in a medication room. Medications are labeled and checked for expiration dates. LPA advised the Administrator to ensure that all the necessary information is properly documented on the CSMAR. LPA interviewed two (2) care staff members. LPA observed two (2) staff were not associated to the facility. Administrator thinks a staff accidentally disassociated them by mistake. During today’s visit, the LPA obtained copies of the following: staff roster, resident roster and current liability insurance. Due to time constraints LPA was unable to finish the annual and will return at another date to continue the annual inspection. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted. A copy of the report and appeal rights was issued.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023

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 09/06/2023 04:32 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: 09/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(4)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (4) Request and be approved for a transfer of a criminal record exemption, as specified in Section 87356(r), unless, upon request for a transfer, the Department permits the individual to be employed, reside or be present at the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in two staff were not associated to the facility, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 09/06/2023
	Plan of Correction
1 2 3 4	Administrator immediately re-associated staff. Administrator stated they think a staff accidentally disassociated the two staff. The POC was cleared during the visit.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023

LIC809 (FAS) - (06/04)

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