427806809-9-21-2022-32-CR-JROS-CJGVBZ-20220921161818

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 427806809
Report Date: 09/21/2022
Date Signed: 09/21/2022 04:18:27 PM

Document Has Been Signed on 09/21/2022 04:18 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, 1000 CORPORATE CNTR DR. #200A
MONTEREY PARK, CA 91754

FACILITY NAME:	ANGELS FOSTER CARE OF SANTA BARBARA		FACILITY NUMBER:	427806809
ADMINISTRATOR:	HOLLY CARMODY		FACILITY TYPE:	430
ADDRESS:	11 WEST VICTORIA ST., #207B		TELEPHONE:	(805) 884-0012
CITY:	SANTA BARBARA	STATE: CA	ZIP CODE:	93101
CAPACITY: 12		CENSUS: 14	DATE:	09/21/2022
TYPE OF VISIT:	Required - 2 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Holly Carmoda		TIME COMPLETED:	11:45 AM

NARRATIVE

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On 09/21/2022 at 9:00 AM, Licensing Program Analyst (LPA) Juliet Robles conducted an unannounced 2-year Required licensing inspection of the Foster Family Agency (FFA). LPA met with Holly Carmody, Executive Director (ED) and Jennifer Mills, Director of Operations/Supervising Social Worker. The facility is licensed to operate a foster family agency in which foster family treatment agency services are provided. LPA and the Executive Director toured the agency and discussed the inspection in detail.

The LPA requested the following items and information: Personnel Report LIC 500, list of current Resource Family Parents (RFP); list of current minors, an updated copy of Administrative Organization, Designation of Administrative Responsibility and a copy of the latest Board of Directors minutes.

At 9:20 AM, LPA and ED did a walkthrough of the entire facility.

PHYSICAL PLANT:

During the inspection, LPA observed the following:

This FFA is located on a second-floor unit of a commercial building. The client and foster parent files are kept in a locked file cabinet in the Executive Director's office. The staff files are also kept in a locked file cabinet. The FFA license, Accreditation, Hotline number and Emergency Disaster plan were all posted in a prominent area. The first aid kit is complete and available.

Currently the FFA has fourteen (14) approved resource family homes, six (6) are active homes, eight (8) are inactive homes and three (3) minor children in placement. There are five (5) staffs at the FFA sub office. The Social Worker to child ratio is within regulations.

At 9:45 AM, LPA reviewed three (3) resource family homes, three (3) clients and two (2) staffs file (See Confidential Name form LIC 811 dated 09/21/22).

SUPERVISORS NAME: Yan Yeung
LICENSING EVALUATOR NAME: Juliet Robles
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022

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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Document Has Been Signed on 09/21/2022 04:18 PM - It Cannot Be Edited

Created By: Juliet Robles On 09/21/2022 at 10:51 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
, 1000 CORPORATE CNTR DR. #200A
MONTEREY PARK, CA 91754

FACILITY NAME: ANGELS FOSTER CARE OF SANTA BARBARA	FACILITY NUMBER: 427806809
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80065(g)(1)

Personnel Requirements

(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's record review, the licensee did not comply with the section cited above in 1 staff did not have a TB test out of 2 staffs file reviewed which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/07/2022
	Plan of Correction
1 2 3 4	Licensee will send proof of correction via email to CCL on or before the due date.

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.

SUPERVISOR'S NAME:

Yan Yeung

LICENSING EVALUATOR NAME:

Juliet Robles

LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022

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, 1000 CORPORATE CNTR DR. #200A
MONTEREY PARK, CA 91754

FACILITY NAME: ANGELS FOSTER CARE OF SANTA BARBARA	FACILITY NUMBER: 427806809
	VISIT DATE: 09/21/2022

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RESOURCE FAMILY HOME RECORDS:

All adults residing in the resource family home (RFH) have obtained criminal record clearances or exemption prior to certification. The agency provides RFH with a signed certificate of approval, which includes the capacity for which the home has been certified, and the age range of children to be served. RFH case records contain written records of the home study, signed statements acknowledging child abuse and neglect reporting responsibilities, and records of training hours for resource family parents.

CHILDREN'S RECORDS (MINOR/NONMINOR DEPENDENT):

The FFA ensures that child's records contain medical consent forms signed by their authorized representative. The FFA also ensures that the children’s records contain copies of the original and Modified Appraisal Assessment, admission agreement and Personal Rights LIC 613.

STAFF RECORDS
A review of Licensing Information System and Guardian on 09/16/22 indicates that all facility staff and RFH are associated to the FFA have DOJ, FBI and child abuse index clearances. Social work personnel are responsible for the evaluation and assessment of a child for placement and for continued supervision of the placement of the child, including direct contact with the child and the resource family parent(s). Executive Director, social work supervisors and social workers have required education and experience. LPA Robles interviewed two (2) staffs at the facility.

During today’s inspection, there is a Type B Section cited CAR 80065(g)(1) Personnel Requirements (1)Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year to or seven days employment or licensure.

LPA provided additional information regarding the inspection and its tools and methods with the Director. The Program website is at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

An exit interview was conducted and copy of LIC 809, LIC 809C, LIC 809D and LIC 811 were provided to the FFA Executive Director.

SUPERVISORS NAME: Yan Yeung
LICENSING EVALUATOR NAME: Juliet Robles
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022

LIC809 (FAS) - (06/04)

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