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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425800464
Report Date: 06/28/2021
Date Signed: 06/28/2021 01:35:42 PM

Document Has Been Signed on 06/28/2021 01:35 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:VISTA DEL MONTEFACILITY NUMBER:
425800464
ADMINISTRATOR:DOUGLAS TUCKERFACILITY TYPE:
741
ADDRESS:3775 MODOC ROADTELEPHONE:
(805) 687-0793
CITY:SANTA BARBARASTATE: CAZIP CODE:
93105
CAPACITY: 266CENSUS: 192DATE:
06/28/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:29 PM
MET WITH:Douglas Tucker, AdministratorTIME COMPLETED:
01:30 PM
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LPAs Darlene Chavez and Kristin Kontilis conducted an Infection Control Inspection on 6/23/2021. After the visit of June 23, 2021, it was discovered that Staff 1 (S1) did not have a criminal record clearance. S1 started working on May 3, 2021 and last day worked was June 14, 2021.
LPA obtained documents pertinent to this visit.

Pursuant to Title 22, Division 6, Chapter 8 of CA Code of Regulations the following deficiencies were cited (refer to 809-D) and an immediate civil penalty of $500 was assessed.
Exit interview conducted, today’s reports were reviewed and emailed to the Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE: DATE: 06/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2021
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 06/28/2021 01:35 PM - It Cannot Be Edited


Created By: Kristin Kontilis On 06/28/2021 at 12:57 PM
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: VISTA DEL MONTE
FACILITY NUMBER: 425800464

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/29/2021
Section Cited
CCR
87411(g)(1)

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87411(g)(1):
…Obtain a California clearance or a criminal record exemption as required by law or Department regulations or
This requirement is not met as evidenced by:
Based on interviews and record review, a criminal background clearance for S1
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Licensee agrees to provide a written declaration stating no staff will work at the facility until a criminal background clearance has been obtained. Declaration will be provided via email to LPA no later than end of business day, June 29, 2021.
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has not been obtained. This poses an immediate health and safety risk to residents in care.
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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:Kelly Burley
LICENSING EVALUATOR NAME:Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2021


LIC809 (FAS) - (06/04)
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