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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425800608
Report Date: 12/21/2022
Date Signed: 12/21/2022 05:36:00 PM


Document Has Been Signed on 12/21/2022 05:36 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 IIFACILITY NUMBER:
425800608
ADMINISTRATOR:DANIEL BONDFACILITY TYPE:
740
ADDRESS:698 ZINK AVENUETELEPHONE:
(805) 689-9237
CITY:SANTA BARBARASTATE: CAZIP CODE:
93111
CAPACITY:6CENSUS: 6DATE:
12/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:58 AM
MET WITH:Timothy Pryko, AdministratorTIME COMPLETED:
05:10 PM
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Licensing Program Analysts (LPAs) Rachael DeLeon and Kristin Kontilis conducted an unannounced on-site one-year Infection Control Inspection visit to the above-named facility. LPA arrived at 11:58 am and was greeted by Staff 1 (S1). Administrator Timothy Pryko arrived at approximately 12:11 pm. Lidia Kravchuk and Daniel Bond, Co-Administrators participated in the inspection. At the time of arrival, there were 6 residents in care, 1 staff and 1 private care staff on duty.
A Mitigation Plan has been submitted to CCLD. LPA explained the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) and is home to non-ambulatory residents with a dementia diagnosis. There are 2 residents currently on hospice.
Entrance interview conducted:
A tour of the physical environment and accommodations were assessed, and the following was noted: LPAs observed Long-Term Care Ombudsman Care poster, bill of rights, Personal rights, Theft and Loss, Facility’s License and Resident’s Rights. LPAs provided technical assistance regarding the Emergency Disaster Plan and the CCLD Complaint Poster. LPAs inspected the one-story facility for fire safety, personal accommodations, and food service. First aid kit was observed to be complete.
Entrance interview conducted.
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 most recently conducted on 6/15/2022. There are approximately two dual carbon monoxide detectors and seven (7) smoke alarms throughout the facility.
The kitchen area was sufficiently stocked with two-day perishables and seven days of non-perishables. Snacks and beverages are readily available for Residents. LPA observed the kitchen cabinets, refrigerator, stove, and counters are clean.
At approximately 12:02 pm, LPAs observed medication cabinet located in a cabinet to the right of the microwave was unlocked and medications in a refrigerator in the unlocked pantry cabinet.
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: 12/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2022
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 II
FACILITY NUMBER: 425800608
VISIT DATE: 12/21/2022
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 The front yard is well maintained and consists of walkways and garden areas. The backyard is well maintained and has a paved patio, gazebo, and garden areas with walkway surrounding the parameter of the facility. The backyard is conducive for outdoor visitation. The recycling bin, green waste bin, and trash bins are standard bins with flip lids.
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.
There are six private bedrooms available for six residents. Each bedroom has a private bathroom. There is a live-in staff room off one hallway that remains locked throughout the day and night.
If any suspected or confirmed cases of COVID-19 are found in the facility a staff will be assigned to only work with those quarantined/isolated individuals and will not work with other COVID negative individuals until cleared by Health Department. Staff will use full PPE with N95 masks and face shields when dealing with any pending or confirmed cases of COVID-19. Precautionary Droplet signs will be posted on any room with quarantine or isolated individuals.
PPE supplies will be located immediately outside those rooms when required. Facility has a 30-day supply of PPE on hand. Facility has plans for delivering medications and meals to any quarantined/isolation resident room.
The facility has proper cleaning and disinfectant sprays. Facility Administrator has a plan in place for when and whom to notify in an outbreak or other emergencies. Administrator will keep a line list of all vaccinated and tested staff/residents in care with dates/results.
Facility has conducted training on infection prevention, symptoms, transmission and PPE use. Facility has non-punitive sick leave polices for staff. Staff who have a respiratory illness are requested to stay home and not report to work.
Activities have been modified to individuals or small groups with social distancing. Residents' medication is delivered in 30-day supplies to the facility. The facility ensures proper cleaning is done on frequently touched surfaces and between any individuals sharing of space or items.
Sinks were well stocked with soap, paper towels and hand washing signs. Staff and resident records are kept in the locked staff office. Facility observes guidance changes and the most up-to-date guidance from CCL-PINS, CDC, CDPH, and local health departments should be followed to remain in compliance. The most stringent orders should be followed by any of these agencies. Administrator Certificate is valid.
Upon entry, LPAs observed Staff 1 (S1) wearing a face covering partially covering S1's face with the nose uncovered. LPA advised S1 that a face covering needs to be worn correctly covering the mouth and nose while in the facility
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2022
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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ABUNDANT CARE II
FACILITY NUMBER: 425800608
VISIT DATE: 12/21/2022
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At approximately 12:04 pm, LPAs observed Home Care Staff 1 (HCS1) enter the dining area with Resident 1 (R1). HSC1 was not wearing a face covering. LPA Kontilis advised HSC1 that a face covering needs to be worn while in the faciity at all times. S2 accompanied R1 to the dining table where there were 3 other residents sitting prior to obtaining the face covering.

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. Copy of this report and Appeal Rights issued via email.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 12/21/2022 05:36 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 II
FACILITY NUMBER: 425800608

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.1
87468.1 Personal Rights: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the facility failed to ensure Staff 1 and Staff 2 were wearing face coverings correctly which poses an immediate health, safety and personal rights risk to residents in care.
POC Due Date: 12/23/2022
Plan of Correction
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Administrator agrees to conduct an infectious control training, review and train staff on all recent PIN’s released for 2022, including mask-wearing mandates, and provide copy of training and staff signatures to CCL by 12/23/2022. Signatures to include first and last name.
Type A
Section Cited
CCR
87465(h)(2)
87465(h)(2) (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 as LPAs observed a medication cabinet located to the right of the stove was unlocked and medications kept in a refrigerator located in the food pantry were not locked posing an immediate health and safety risk to residents in care.
POC Due Date: 12/23/2022
Plan of Correction
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Administrator agrees to conduct an in-service training to include CCR 87465 in its entirety by 12/23/2022. Proof of training will be emailed to LPA to include but not limited to description, duration of time, trainee, attendees (w/signatures and first and last name).
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: 12/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2022
LIC809 (FAS) - (06/04)
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