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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850043
Report Date: 06/07/2024
Date Signed: 06/07/2024 01:57:38 PM

Document Has Been Signed on 06/07/2024 01:57 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/
DIRECTOR:		HERNANDEZ, ARNOLDFACILITY TYPE:
775
ADDRESS:5385 HOLLISTER AVE BLD9 STE215TELEPHONE:
(805) 681-1676
CITY:GOLETASTATE: CAZIP CODE:
93111
CAPACITY: 30CENSUS: 11DATE:
06/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:26 AM
MET WITH:Arnold Hernandez, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced Annual Required Inspection. The facility has submitted a Mitigation Plan to the Department. Administrator Arnold Hernandez was present at the time of the visit. At the time of arrival, there were eleven (11) staff (including Administrator) on duty and nine (9) participants present. LPA informed Administrator of the purpose of the visit.
LPA conducted a physical tour of the facility. The facility operates in a leased building through ANKH Life Skills and contracts with Tri-Counties Regional Center. The facility staff are trained in CPI (non-crisis prevention intervention) and is a “hands off” facility.
The program provides community activities, recreation activities, and educational opportunities to participants with an Autism diagnosis. Participants participate in community service activities, music activities, individualized life skills, recreational activities such as basketball and volleyball, gardening, maintaining the nearby coy and duck ponds, and outings/excursions to local eateries, movie theatres, beaches and parks.
The facility has an administration office, a conference room, three (3) bathrooms, a locked supply room, computer lab, three (3) activity rooms, an infirmary, two relaxation rooms; a common area with a television set, board games, and musical instruments; lockers and hangers for personal belongings and a kitchen. The kitchen area consists of a refrigerator, microwave, sink and counter area. Sharps and centrally stored medications are kept in locked cabinets in the kitchen. All cleaning agents, disinfectants, and chemicals are stored in a locked supply room.
A tour of the facility revealed that the program site is clean, safe, sanitary, and in good repair. The main entrance into the facility is through a gate leading into a courtyard. Participants can sit outside with two tables and two umbrellas and a garden area. There is a ramp with wheelchair access that enters the building. There are no bodies of water. The facility has six (6) vehicles available for participant transportation.
Please continue to 809-C, Pg 2.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2024
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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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: PALS SANTA BARBARA AUTISM CENTER
FACILITY NUMBER: 425850043
VISIT DATE: 06/07/2024
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 There is a First Aid kit in the kitchen, and one in each of the six facility vehicles. The two (2) fire extinguishers are located in the entrance and the exit of the building as well as one in each van. The fire extinguishers were last serviced on 10/24/2023. There are 12 carbon monoxide/smoke alarms all in good working order.
LPA observed appropriate Community Care Licensing posters including Complaint poster, Mandated Reporter poster, Personal Rights, Emergency Disaster Plan, and COVID-19 guidelines.
Participants bring their own food and snacks; water is provided by the facility staff.
All staff have received a criminal background clearance and are associated to the facility. Records reviewed indicate all personnel and residents' records are current and up-to-date.

Pursuant to Title 22, Division 6, Chapter 8 of CA Code of Regulations, no citations have been issued.

Exit interview conducted. Copy of the report issued at the time of the visit.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024
LIC809 (FAS) - (06/04)
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