425850025-3-10-2022-29-AS-KBUY-CCEVBB-20220311151717

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425850025
Report Date: 03/10/2022
Date Signed: 03/10/2022 03:14:43 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/19/2021 and conducted by Evaluator Jeannette Olson

COMPLAINT CONTROL NUMBER: 29-AS-20211019091255

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: 87	DATE:	03/10/2022
		UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Amy Bowman, Wellness Director		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff are not providing authorized representative with resident records
Staff are not returning authorized representative's calls/emails

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Olson and Licensing Program Manager (LPM) Burley conducted an unannounced complaint visit to issue final findings. LPA Diaz conducted the investigation, reviewed facility documents and conducted interviews with the staff and residents. LPA interviewed staff on 2/10/22 at 4:22pm and Wellness director at 4:40pm. LPA interviewed residents on 2/11/22 at 4:19pm.
On the allegation: Staff are not providing authorized representative with resident records. Based on an interview with the Administrator, the local Public Health Department held an onsite COVID-19 vaccine clinic at the facility. After vaccines were given to the residents, the Health Department provided the residents with their vaccination cards. The vaccination cards indicated the type of vaccine and the date that the vaccine was administered to the resident. The Administrator stated the facility did not collect or hold the vaccination cards and instead each resident held onto to their own vaccination card. However, the facility collected the data from the vaccination cards and logged the data within facility records.
Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20211019091255

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/10/2022

NARRATIVE

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The Wellness Director also confirmed that the vaccination data has been stored within facility records. The Administrator stated, the facility would release medical documents to any authorized representative. The Administrator stated that Resident 1 (R1) moved into the facility on 2/22/21 and R1 moved out of the facility on 3/30/21. R1 received the first vaccine dose on 2/24/21, and R1 did not receive the second vaccine while staying at the facility. The facility was never contacted by an authorized representative in search of medical or vaccine records. The LPA attempted to contact the reporting party (RP) 3 times via telephone and email. LPA was unable to reach the RP for each attempt made and the RP did not return calls or emails.
Based on the interviews and records reviewed, the allegation is deemed unsubstantiated at this time.

On the allegation: Staff are not returning authorized representative's calls/emails. According to the Administrator, the Wellness department and the Administrator were never contacted by a resident’s authorized representative in search of medical or vaccine records. The Administrator also stated that they did not receive any emails or calls from R1’s responsible party requesting vaccine or medical records. The Wellness Director confirmed that the facility has not been contacted by R1’s representative or any family representatives requesting vaccination records. The LPA attempted to contact the Reporting Party (RP) 3 times via telephone and email. LPA was unable to reach the RP for each attempt made and the RP did not return calls or emails. Based on the interviews and records reviewed, the allegation is deemed unsubstantiated at this time.
Exit interview, report given.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022

LIC9099 (FAS) - (06/04)

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