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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425800484
Report Date: 09/21/2021
Date Signed: 09/21/2021 04:41:08 PM

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 CAREFACILITY NUMBER:
425800484
ADMINISTRATOR:TIMOTHY PRYKOFACILITY TYPE:
740
ADDRESS:5506 SOMERSET DRIVETELEPHONE:
(805) 576-7470
CITY:SANTA BARBARASTATE: CAZIP CODE:
93111
CAPACITY:6CENSUS: 6DATE:
09/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:53 PM
MET WITH:Timothy PrykoTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Kristin Kontilis conducted an onsite one-year infection control annual visit to the above-named facility. LPA met with Timothy Pryko, Administrator and explained the purpose of the visit.
LPA conducted a physical tour of the facility. The facility has submitted a Mitigation Plan to the Department. The facility has an entry station at the front of the building. Upon entry, staff, visitors, and residents returning from an outing are required to sign-in, complete a symptom questionnaire, and have a temperature screening. All documentation is kept in a a binder on a daily basis. The entry station has PPE gear, hand sanitizer, and disinfecting wipes along with a thermometer.
Entrance interview conducted.
There are currently 6 residents residing in the facility. The facility is home to residents with a dementia diagnosis. There are currently three (3) residents on hospice.
A tour of the physical environment and accommodations were assessed, and the following was noted: LPA observed the required posting of the complaint poster, bill of rights and Resident’s Rights. LPA inspected the one-story facility for fire safety, personal accommodations, and food service. First aid kit was observed to be complete.
The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked. The facility was seen to be in good repair inside and outside. Fire inspection was conducted on 9/01/2021.
The backyard has a covered patio with outdoor furniture and sitting areas. There are no bodies of water. The recycling bin, green waste bin, and trash bins are standard bins with flip lids. A locked private staff room is located in the main part of the house near the front entrance.
The living room and dining area are neat and clean. The facility maintains a comfortable temperature at 75 degrees Fahrenheit (F). Hallways, bedroom doors and walls are in good repair.
Please continue to 809-C, Pg 2..
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ABUNDANT CARE
FACILITY NUMBER: 425800484
VISIT DATE: 09/21/2021
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 The facility has 6 private bedrooms. Bedroom #1 has a shared bathroom off the hallway. Bedrooms 2-6 each have a private bathroom. Each resident’s room is furnished with overhead lights to provide sufficient lighting, a nightstand, and a bed. The bathrooms have secure grab bars and no skid flooring.
Exit interview conducted. Copy of report emailed. No deficiencies noted.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
LIC809 (FAS) - (06/04)
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