425850081-10-27-2025-29-AS-MJES-DMUSEH-20251027134844

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425850081
Report Date: 10/27/2025
Date Signed: 10/27/2025 01:49:09 PM

Document Has Been Signed on 10/27/2025 01:49 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:	STADIUM PLACE HOME		FACILITY NUMBER:	425850081
ADMINISTRATOR/ DIRECTOR:	CINDY BAKER		FACILITY TYPE:	734
ADDRESS:	961 STADIUM PLACE		TELEPHONE:	(805) 691-9036
CITY:	SOLVANG	STATE: CA	ZIP CODE:	93463
CAPACITY: 5		CENSUS: 4	DATE:	10/27/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:04 AM
MET WITH:	Administrator, Cindy Baker		TIME VISIT/ INSPECTION COMPLETED:	02:00 PM

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At 9:30am on 10/27/2025, Licensing Program Analyst (LPA) Jeffries arrived at the facility unannounced to conduct a annual facility inspection visit. LPA accompanied by Tri Counties Regional Center (TCRC), Quality Assurance Representative, Stephanie Cole (QA). QA and LPA met with Facility Administrator, Cindy Baker, announced who they are and the reason for the visit.

This facility is a five bedroom, three bathroom, one office, grand living room, dinging room, activity area, and an open nurses station adjacent to the living room. Medication are stored in a locked rolling medication cabinet. There is a completed first aide kit and ample medical supply to address the needs of residents in care. There is ample incontinence supplies and personal perfective equipment (PPE) supplies on hand. All resident rooms are equipped according to regulations. All bathrooms meet regulation requirements. Water temperature was tested and within regulation range of 105*-120*(f). There are fire extinguishers located throughout the facility that are all primed and in the green as working. There are smoke detectors that are dual carbon monoxide detectors in each room and are hard wired and green led indicating being functional. All hallways, passage ways and door ways are free and clear of obstacles. LPA noted that the garage door conversion is lacking dry-wall and appears unfinished at this time. LPA noted that the facility has at least seven days of non-perishable foods and at least two days of perishable foods on hand for five residents and staff. LPA noted that there is emergency water supply located in garage. LPA noted that this facility has a full function generator that automatically powers the entire facility in the event of a power outage. LPA noted that the facility was clean and in good repair. LPA conducted the full physical inspection with TCRC QA.

Administrator, QA and LPA conducted a full review of the annual care tools for this facility. LPA reviewed staff files, client files, Centrally Stored Medication Records, Emergency Disaster Plan and Infection control plan. LPA screen all employes to be fingerprint cleared. LPA noted that there were no violations or citations as a result of a full annual inspection. Exit interview, report read, and report provided.

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Mark Jeffries
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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