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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850043
Report Date: 02/13/2024
Date Signed: 02/13/2024 04:45:35 PM

Document Has Been Signed on 02/13/2024 04:45 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: 13DATE:
02/13/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:36 PM
MET WITH:Arnold Hernandez, AdministratorTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Olson conducted an unannounced subsequent Case Management visit to issue final findings on an Incident that happened on 7/18/23. LPA conducted the investigation with Tri-Counties Regional Center Quality Assurance Specialist (QAS) Tracy Jackson and interviewed staff on 7/24/23, 7/25/23, and 7/26/23. LPA and QAS met with the Administrator and explained the purpose of the visit.

CCL received an incident report on 7/25/23 stating that on 7/18/23 Client 1 (C1) exhibited agitated behavior and self-injured. On 8/3/24 LPA and QAS toured the facility and interviewed Administrator, Staff 1 (S1) and Staff 2 (S2) regarding the incident. LPA and QAS requested relevant documents.

Interviews with Staff revealed they were not trained on restraints and did not receive the proper training to support C1. Administrator stated they provided staff with a schedule for C1, token board, and transportation contract. LPA and QAS reviewed staff paperwork and observed Staff 1 had expired CPR, First Aid and Emergency Intervention training. Staff 2 had no training records, CPR, First Aid or Emergency Intervention training on record. Administrator stated the training schedule was done in corporate and they would provide it to CCL.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to 809-D).

Exit interview conducted. Copy of report and appeal rights issued during the visit.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 02/13/2024 04:45 PM - It Cannot Be Edited


Created By: Jeannette Olson On 02/13/2024 at 03:53 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PALS SANTA BARBARA AUTISM CENTER
FACILITY NUMBER: 425850043

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/15/2024
Section Cited
CCR
82165(b)(2)

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82165 Emergency Intervention Staff Training (b) Staff...shall have a minimum of sixteen hours of emergency intervention training and be certified for having successfully completed the training. (2) Staff shall maintain valid certification. This requirement was not met as evidenced by:
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Administrator agreed to sumbit proof that all staff have recieved 16 hours of emergency intervention training.
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Based on interviews and record review, the licensee did not comply in the section sited above when staff did not have valid Emergency intervention training, which posed an immediatel health and safety risk to residents in care.
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Type B
02/15/2024
Section Cited
CCR82075(f)

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82075 Health-Related Services (f) Staff responsible for providing direct care and supervision shall receive and maintain current training in first aid and cardiopulmonary resuscitation from persons qualified by agencies including, but not limited to, the American Red Cross.
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Administrator agreed to sumbit proof that all staff have recieved vaild first aid and CPR training.
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This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not comply in the section sited above when staff did not have valid first aid and CPR training, which posed a potential 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 Burley
LICENSING EVALUATOR NAME:Jeannette Olson
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/13/2024 04:45 PM - It Cannot Be Edited


Created By: Jeannette Olson On 02/13/2024 at 03:59 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PALS SANTA BARBARA AUTISM CENTER
FACILITY NUMBER: 425850043

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/20/2024
Section Cited
CCR
82065.1(d)(1)

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82065.1 Personnel Qualifications and Duties(d) The licensee shall develop, maintain, and implement a written plan for the orientation, continuing education, on-the-job training and development, supervision, and evaluation of all direct care staff. (1) Direct care staff shall receive a minimum of
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Administrator agreed to submit a plan on how they will implement training, development, supervision and evaluation all direct care staff.
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8 hours a year of training, documented. Based on interviews and record review, the licensee did not comply in the section sited above when staff did not have 8 hours of training, which posed a potential 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 Burley
LICENSING EVALUATOR NAME:Jeannette Olson
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024


LIC809 (FAS) - (06/04)
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