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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425800484
Report Date: 09/01/2023
Date Signed: 09/14/2023 04:31:24 PM


Document Has Been Signed on 09/14/2023 04:31 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 CAREFACILITY NUMBER:
425800484
ADMINISTRATOR:TIMOTHY PRYKOFACILITY TYPE:
740
ADDRESS:5506 SOMERSET DRIVETELEPHONE:
(805) 576-7470
CITY:SANTA BARBARASTATE: CAZIP CODE:
93111
CAPACITY:6CENSUS: 6DATE:
09/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Timothy Pryko, AdministratorTIME COMPLETED:
02:45 PM
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Licensing Program Analysts (LPAs) Darlene Chavez and Kristin Kontilis conducted an unannounced required Annual Inspection at the facility. The facility is a one-story home which is licensed as a Residential Care Facility for the Elderly (RCFE) with a dementia diagnosis. The facility has been approved for a hospice waiver for 4 residents and has a fire clearance for 6 non-ambulatory residents, one of which can be a bedridden resident. Upon arrival, there were six residents in care and two staff on duty. Currently there are six residents residing in the facility with 1 resident on hospice. Administrator Timothy Pryko arrived at approximately 9:59 am. LPAs explained the purpose of the visit.

Entrance interview conducted.
A tour of the physical environment and accommodations were assessed. The following was noted: LPA observed the required posting of the complaint poster, bill of rights and Resident’s Rights. LPA inspected the 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, doors, floors, and floor coverings were checked. The facility was seen to be in good repair inside and outside. There is one fire extinguisher located in the common area, last serviced on 1/15/2023. The carbon monoxide alarm and smoke alarms are in good working order. Medications are kept in a locked centrally stored cabinet.
The kitchen, living room and dining area are neat and clean. The facility maintains a comfortable temperature. Hallways, bedroom doors and walls are in good repair.
The kitchen has a refrigerator, dishwasher, toaster, hot water teapot, and a stove-top oven. LPAs observed the kitchen stove has knobs in place and is accessible to residents in care. Between 10:15 am and 11:09 am, the refrigerator located in the kitchen was measured at 43.1 degrees Fahrenheit (F) and the freezer was measured at 5.8 degrees F. The refrigerator located in the hallway closet was measured at 35 degrees (F) and the freezer was measured at 17.3 degrees (F).
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: 09/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2023
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


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: 09/01/2023
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 The facility has 5 private bedrooms with private baths. Bedroom #1 is a private bedroom with access to the bathroom across the hallway. Each resident’s room is furnished with overhead lights to provide sufficient lighting, a nightstand, and a bed.
The laundry area and storage area are located off the hallway. Cleaning agents and detergents are kept locked and inaccessible to residents in care.
The backyard consists of a covered and fenced patio area with chairs and tables. The patio has planters, walkways, and built-in garden areas. The trash, recycling, and green waste cans are standardized cans located outside the facility.
There is a hard-wired dual carbon monoxide detector and smoke alarm system in every room and each hallway.
LPAs observed a comfortable room temperature throughout the facility.
Residents participate in activities based on their individual interests and preferences, including musical entertainment, painting, drawing, social activities, and puzzles. Outdoor activities include socializing, leisure walks, visitors from community organizations, and seasonal celebrations.
Residents records were reviewed and were found to be current and in good order.
Staff records were reviewed. Staff training and required documents are in good order. All staff have received a criminal background check and have been properly associated to the facility.

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



Exit interview conducted. Deficiencies noted. A copy of this report and appeal rights issued at the time of the visit..
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/14/2023 04:31 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)
87555(b)(21) General Food Service Requirements: Freezers of adequate size shall be maintained at a temperature of 0 degrees F (-17.7 degrees C), and refrigerators of adequate size shall maintain a maximum temperature of 40 degrees F (4 degrees C)…

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations and interviews conducted the licensee did not comply with the regulation above when the kitchen refrigerator measured at 43.1 degrees (F) and the hallway freezer measured at 17.3 degrees F posing a potential health and safety risk to residents in care.
POC Due Date: 09/08/2023
Plan of Correction
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Administrator agrees to calibrate the appliances on a regular basis. Administrator agrees to submit a temperature log of the temperatures taken on a daily basis. Administrator agrees to purchase a thermometer to ensure a more accurate reading of the appliances. Administrator agrees to provide a proof of purchase for the thermometer(s).
Type B
Section Cited
CCR
87705(d)
87705(d) Care of Persons with Dementia: In addition to requirements specified in Section 87303, Maintenance and Operation, safety modifications shall include, but not be limited to, inaccessibility of ranges, heaters, wood stoves, inserts, and other heating devices to residents with dementia.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations and interviews conducted, the Licensee did not comply with the regulation above when five stove handles/knobs were in place on the kitchen stove and accessible to residents in care which poses a potential health and safety risk to residents in care.
POC Due Date: 09/08/2023
Plan of Correction
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Administrator removed handles from the stove and placed in a locked drawer located near the stove. Administrator agrees to conduct training with staff to comply with the regulation. Administrator agrees to submit written training document including date, time of training along with description of the training conducted.
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 BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 09/14/2023 04:31 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(h)
87705(h): Care of Persons with Dementia: Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations and interviews conducted the Licensee did not comply with the regulation above as the gate on the southside of the facility does not have a self-closing latch and the front patio gate has the self-closing latch on the outside of the gate making it inaccessible to residents/staff when exiting the facility. This poses a potential health and safety risk to residents in care.
POC Due Date: 09/01/2023
Plan of Correction
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Administrator agreed to reverse the self-closing latch on the inside of the gate. Administrator repaired the self-closing latch to work properly. Plan of correction completed during the visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4