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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601675
Report Date: 08/30/2022
Date Signed: 08/30/2022 12:35:01 PM

Document Has Been Signed on 08/30/2022 12:35 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. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SANTA BARBARA GUEST HOME #2FACILITY NUMBER:
198601675
ADMINISTRATOR:LEAH AVILAFACILITY TYPE:
740
ADDRESS:725 SANTA BARBARA ST.TELEPHONE:
(626) 796-6600
CITY:PASADENASTATE: CAZIP CODE:
91101
CAPACITY: 6CENSUS: 6DATE:
08/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:33 AM
MET WITH:Avila, Leah Administrator TIME COMPLETED:
12:43 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Administrator Leah Avila and explained the purpose of the visit. Administrator certificate expires October 21, 2023 and last fire drill was on 10/052021

Structure:
The Facility is a 1 story home in residential area with 3 shared rooms, 1 staff room, 2 bathrooms, a kitchen, living room, dining room and detached garaged. There is a large backyard area on the premises with chairs and shaded area in front of home. All the resident’s bedrooms are spacious and will easily accommodate the resident's furnishings. The passageway and walkways are free of hazard and free from obstruction. On today's tour, LPA was able to inspect all 3 bedrooms. Facility is currently 4 residents 60 years and older and two (2) resident under the age of 60. Vendored with Frank Lanterman Regional Center,

The following were observed/inspected:

· COVID-19 signs are posted at the entrance. Visitors are screened in the main entrance and a log is kept.
· LPA was screened for this visit.
· Infection control signs and other COVID-19 signs are posted throughout the facility in the bathrooms, kitchen, and hallway to promote hand washing, cough/sneeze etiquette, and physical distancing.
· Facility has ability to isolate resident(s).
· 3 client rooms, common areas, bathrooms, and outdoor physical plant was inspected.
· 3 client rooms were not equipped with alcohol-based hand sanitizer but available at facility.
· Six (6) centrally stored client medication records were reviewed.
· Staff responsible for direct care and supervision were observed wearing masks.
· Clients were not at facility at time of visit.
· Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 08/30/2022 12:35 PM - It Cannot Be Edited


Created By: Alberto Lopez On 08/30/2022 at 11:51 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. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SANTA BARBARA GUEST HOME #2
FACILITY NUMBER: 198601675

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Temperture measured 102.4 in kitchen sink and 103.3 in Bathroom sink which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/31/2022
Plan of Correction
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Administrator will adjust water temperture to be within 105 degress and 120 degress F and provide proof to LPA by POC date.
****Administrator adjusted water temperture during visit and no further action is required****
Type A
Section Cited
CCR
87465(e)
Incidental Medical and Dental Care Services
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 2 of 6 persons which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/02/2022
Plan of Correction
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Administrator will obtain PRN letters and labels for all residents in care and send proof (photo) to LPA by POC date.
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:Stefanie Coronel
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2022


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/30/2022 12:35 PM - It Cannot Be Edited


Created By: Alberto Lopez On 08/30/2022 at 11:51 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. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SANTA BARBARA GUEST HOME #2
FACILITY NUMBER: 198601675

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. There are 3 sofa chairs and one old mattress on the gorunds which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/06/2022
Plan of Correction
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Licensee will remove/dispose of the 3 sofa chairs and old mattress and send proof by POC date to LPA.
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. One window screen on side of home is in need of repair or replacement which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/06/2022
Plan of Correction
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Administrator will repair or replace the window screen by POC date and send photo as proof to LPA.
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:Stefanie Coronel
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2022


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. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SANTA BARBARA GUEST HOME #2
FACILITY NUMBER: 198601675
VISIT DATE: 08/30/2022
NARRATIVE
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See page 809 D for deficiencies cited and for Plan of Correction (POC).

An exit interview was conducted. This report was reviewed with Leah Avila (administrator) and a copy of this report and appeal rights were provided to Administrator Leah Avila
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4