425850270-6-26-2026-29-AS-MJES-DVERJ2-20260626130313

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425850270
Report Date: 06/26/2026
Date Signed: 06/26/2026 01:19:46 PM

Document Has Been Signed on 06/26/2026 01:19 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:	ST. ANDREWS RESIDENCE, INC. 1		FACILITY NUMBER:	425850270
ADMINISTRATOR/ DIRECTOR:	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: 6	DATE:	06/26/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	07:42 AM
MET WITH:	Administrator, Rossano Abata		TIME VISIT/ INSPECTION COMPLETED:	01:28 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At 7:40am on 06/26/2026, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct the facility annual inspection. LPA met with Administrator, Rossano Abata announced who he is and the reason for the visit. This facility is a is a seven bedroom, four bathrooms, living room, dining room, laundry room and kitchen. Six rooms are designated as single client rooms with room number #5 being double client occupancy. Client room number 3 is designated for client isolation room in the event of infection control measures are needed. Bedroom number seven is designated as staff bedroom. There is a back yard with a table, chairs and umbrella for client and visitor use. There is a garage where supply's are stored. Medications are stored in the locked walk-in closet at the front entrance. There is a complete first aide kit located in the medication closet. Client bedrooms are properly furnished and clean linins per regulation requirements. All bathrooms have liquid soap, paper towels and rubber mats. LPA tested water temperature throughout the facility and noted that it is within regulation permitters of (105-120 (f)). LPA observed facility food supply to have at least two days of perishable foods and at least seven days of non-perishable foods on hand for six clients and staff. LPA reviewed client files, staff files, staff training, centrally stored medication records (CSMR), infection control, and emergency disaster plans all with no issues. LPA observed and tested the hard wired smoke detectors with combination carbon monoxide detectors to be throughout the facility and functioning properly. LPA noted that all hallway, passages and door ways were free and clear of debit. LPA noted black mold in bathroom number one that required mitigation and a citation was issued. LPA conducted a full review of the annual care tools modules and noted that care tools resulted in no violations and no citations for this annual facility 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: 06/26/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2026

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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Document Has Been Signed on 06/26/2026 01:19 PM - It Cannot Be Edited

Created By: Mark Jeffries On 06/26/2026 at 09:30 AM

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: ST. ANDREWS RESIDENCE, INC. 1	FACILITY NUMBER: 425850270
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/26/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in allowing black mold to accumulate in hallway bathroom ceiling, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/10/2026
	Plan of Correction
1 2 3 4	Administrator agrees to have black mold revoved and repair ciling in hallway bathroom. Administrator will provied contractor invoice and/or material recipt and photographs of repait to LPA Jeffries via email or text on or before 07/10/2026,

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Kelly Burley
NAME OF LICENSING PROGRAM MANAGER:

	Mark Jeffries
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/26/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2026

LIC809 (FAS) - (06/04)

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