425850270-7-12-2022-29-AS-MJES-CG9JC4-20220712065515

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425850270
Report Date: 07/11/2022
Date Signed: 07/12/2022 06:55:44 AM

Document Has Been Signed on 07/12/2022 06:55 AM - 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:	ST. ANDREWS RESIDENCE, INC. 1		FACILITY NUMBER:	425850270
ADMINISTRATOR:	ABATA, ROSSANO D.		FACILITY TYPE:	735
ADDRESS:	259 MOONCREST LANE		TELEPHONE:	(805) 287-9243
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93455
CAPACITY: 6		CENSUS: 5	DATE:	07/11/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Administrator/Rossando Abata		TIME COMPLETED:	01:00 PM

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At 11:00am on 07/11/2022, Licensing Program Analyst (LPA) Jeffries conducted an scheduled pre-licensing visit/relocation visit. LPA met with applicant Administrator, Rossano Abata. Administrator took LPA on a tour of the facility and the following is noted:

Medications: Medications will be stored in the left side locked closet in the entry way.

Physical Plant: The facility is a 6 bedroom for clients and 2 bedrooms designated for staff, 4 bathroom with a kitchen, dining room, living room, and through a locked door adjunct to the kitchen there is the staff room and bathroom (7 total bedrooms and 4 total bathrooms), laundry room, and small storage area in a partial garage space. Facility is clean, sanitary and in good repair. Indoor and outdoor passageways, porches, and other areas of potential hazard are free of obstructions. The facility does not have any pools or bodies of water. The facility does not store or allow firearms or ammunition to be stored at the facility. Any dangerous products, tools, soaps, detergents, and cleaning supplies are will be stored in the locked storage area of the partial garage. All window screens are clean and in good repair. Facility temperature is between 68-85 F degrees, 68 degrees at the time of per licensing location change inspection. Smoke and carbon monoxide detectors were tested and operating properly throughout the facility. The outdoor side gates both have self-closing mechanisms.

Bedrooms: The facility has six resident bedrooms, one with double occupancy and five with single occupancy. Bedrooms have beds for each resident with mattress, mattress pads, bed springs and pillows which are clean and in good repair. Mattresses and pillows are flame-retardant. The rooms have dressers and closet space for residents. The rooms are furnished with chairs and proper lighting and/or lamps in each room for clients.

Continued on 809-C.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2022

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: ST. ANDREWS RESIDENCE, INC. 1	FACILITY NUMBER: 425850270
	VISIT DATE: 07/11/2022

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Bathrooms: The facility has 3 bathrooms for residents and one for staff. All bathrooms have a toilet, sink, and showers. Bathrooms are located near resident rooms. Water temperatures in were tested within regulation range.
There are night-lights in the hallways throughout the facility.
Supplies: The facility has a supply of resident personal hygiene supplies, clean linens, towels and wash clothes. Administrator states they will be transferring these items from the prior facility.
Food Service: The dining room is next to the kitchen. The refrigerator is in good working order in the kitchen and there are two other refrigerators in good working order in the locked partial garage. A seven day supply of non-perishable food and 2 day supply of parishable foods is present that the other facility and will be transferred to this facility on the day move. Administrator states they will be transferred from the prior licensed facility. All kitchen, food storage, and preparation areas are clean. The kitchen sink’s water temperature was recorded with in regulation parameters.
Records: The facility has confidential storage for personnel and client records, they will be kept in a locked filing cabinet between kitchen and dining room.
Administration: The facility has emergency plan and phone numbers posted, Residents rights, Rights of person with disability's, and Licensing Complaint Poster is posted in front entry way of the facility next to and across from the medication closet of the facility.
Activities: The facility has art supplies, movies, and crossword puzzles as well as additional activity supplies for clients. There is an outdoor space with a shaded area (umbrella) and furnished for outdoor use. There is at least one common room available to residents for visitors.
Miscellaneous: The facility has a first aid kit at the former facility. The facility does not have an operating telephone available at this time, Comcast has been contacted they will move the prior facility number to this new facility location when they physically move [(805) 287-9242]. Facility has emergency lighting and supplies to include flashlights with batteries. Vehicle used to transport residents is in safe operating condition, the vehicle is a 2016 Honda Pilot and a 2017 Nissan Sentra, both with current registration and insurance to safely transport clients

LPA has reviewed LIC200 and STD850 Fire Inspection forms and noted this facility is for capacity of 6 with 6 non-ambulatory clients.

Exit interview, report singed, copy emailed.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2022

LIC809 (FAS) - (06/04)

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