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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801580
Report Date: 07/29/2021
Date Signed: 07/29/2021 02:09:13 PM

Document Has Been Signed on 07/29/2021 02:09 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:ABUNDANT CARE IIIFACILITY NUMBER:
425801580
ADMINISTRATOR:DANIEL BONDFACILITY TYPE:
740
ADDRESS:4589 AUHAY DRIVETELEPHONE:
(805) 845-8490
CITY:SANTA BARBARASTATE: CAZIP CODE:
93110
CAPACITY: 6CENSUS: 6DATE:
07/29/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Timothy Pryko, AdministratorTIME COMPLETED:
02:30 PM
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Licensing Program Analyst Kristin Kontilis conducted a Case Management visit to address the deficiencies noted during complaint control # 29-AS-20190910101511 investigation visit conducted on 7/29/2021.

During facility tour at 11:48 AM, LPA observed that Staff #1 (S1) is fingerprint cleared and not associated to the facility. At approximately 12:11 pm, LPA confirmed S1's identification.

At approximately 12:26 pm, Administrator Pryko stated S1 is filling in for the day due to other staff being on vacation. Administrator also stated S1 arrived at 7:00 am and would be leaving at approximately 12:30 pm.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Civil penalties assessed in the amount of $500.00.

Exit interview conducted, today's report and civil penalty were reviewed and emailed to Administrator. Report issued. Appeal rights issued.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE: DATE: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2021
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 07/29/2021 02:09 PM - It Cannot Be Edited


Created By: Kristin Kontilis On 07/29/2021 at 12:28 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: ABUNDANT CARE III
FACILITY NUMBER: 425801580

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
07/29/2021
Section Cited
CCR
87355(e)(2)

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87355 Criminal Record Clearance. (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)...
This requirement is not met as evidenced by:
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S1 requires to obtain criminal transfer. Staff provided copies of criminal background clearance transfer request, LIC508 and photo identification to LPA.
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Based on interviews and record review, the licensee did not comply with the section cited above as the licensee did not ensure that S1 was associated prior to allowing S1 to work, which poses an immediate health and safety risk to persons 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: 07/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2021


LIC809 (FAS) - (06/04)
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