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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850082
Report Date: 03/24/2025
Date Signed: 03/24/2025 12:44:30 PM

Document Has Been Signed on 03/24/2025 12:44 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:MOUNTAIN RIDGE HOME CORPFACILITY NUMBER:
425850082
ADMINISTRATOR/
DIRECTOR:
BAKER, CINDYFACILITY TYPE:
734
ADDRESS:3271 OLD HIGHWAY 246TELEPHONE:
(650) 267-9482
CITY:SANTA YNEZSTATE: CAZIP CODE:
93460
CAPACITY: 5CENSUS: 5DATE:
03/24/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:33 AM
MET WITH:Administrator, Cindy BakerTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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At 10:00am on 03/24/2025, Licensing Program Analyst (LPA) Jeffries arrived at the facility unannounced to conduct a case management visit. LPA accompanied 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. Case Management visit was made due to Serious Incident Report (SIR) submitted on 03/14/2025 for an incident that took place on 02/22/2025.

QA and LPA conducted staff interviews, conducted facility tour, make observations of all clients in care. LPA noted extensive administrative action, including but not limited to staff training, Register Nurse observations of Clients in care, Staff scheduling adjustments and staff care. LPA requested training documentation for Staff 1 and Staff 2 (S1 and S2). LPA will review documentation and follow up with Licensing Program Manager on status and updates on SIR submitted and facility actions pertaining to SIR in question.

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: 03/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2025
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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