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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850043
Report Date: 08/03/2023
Date Signed: 08/03/2023 01:08:41 PM

Document Has Been Signed on 08/03/2023 01:08 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:PALS SANTA BARBARA AUTISM CENTERFACILITY NUMBER:
425850043
ADMINISTRATOR:HERNANDEZ, ARNOLDFACILITY TYPE:
775
ADDRESS:5385 HOLLISTER AVE BLD9 STE215TELEPHONE:
(805) 681-1676
CITY:GOLETASTATE: CAZIP CODE:
93111
CAPACITY: 30CENSUS: 10DATE:
08/03/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Arnold Hernandez, AdministratorTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Olson conducted a Case Management - Incident visit to investigate an incident the facility self-reported. LPA was accompanied by Tracy Jackson, Quality Assurance Specialist (QAS) for Tri-Counties Regional Center. LPA and QAS met with Arnold Hernadez, Administrator and explained the purpose of the visit.

On 7/25/23, CCL received an incident report stating that on 7/18/23, Client 1 (C1) exhibited agitated behavior and self-injured. LPA and QAS toured the facility and interviewed Administrator regarding the incident. LPA and QAS requested relevant documents. At this time, further investigation is needed. LPA will follow up at a later date to continue the investigation.

Exit interview conducted and a copy of the report was issued.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE: DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2023
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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