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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801158
Report Date: 10/18/2022
Date Signed: 10/18/2022 05:59:52 PM


Document Has Been Signed on 10/18/2022 05:59 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:MESA CAREFACILITY NUMBER:
425801158
ADMINISTRATOR:VALENTYNA POLUNETSFACILITY TYPE:
740
ADDRESS:2424 CALLE SORIATELEPHONE:
(805) 965-2428
CITY:SANTA BARBARASTATE: CAZIP CODE:
93109
CAPACITY:6CENSUS: 6DATE:
10/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:47 PM
MET WITH:Valentyna Polunets, AdministratorTIME COMPLETED:
05:55 PM
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Licensing Program Analysts (LPAs) Olson and Kontilis conducted an unannounced Annual Infection Control Inspection of the facility. LPAs arrived at 2:47 PM and was greeted by Administrator Valentyna Polunets. LPA explained the purpose of the visit.
At the time of arrival, there was one staff on duty and six residents in care. Co-Administrator Alex Polunets arrived to the facility at approximately 3:10 pm.
Entrance interview conducted.
The facility is a one-story facility located in a residential area. A tour of the physical environment and accommodations were assessed and the following was noted: LPAs observed the required posting of the complaint poster, bill of rights and Resident’s Rights. LPAs inspected the one-story facility for fire safety, personal accommodations, and food service.
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. LPAs observed the fire inspection was last conducted on 4/5/2022. LPA Olson observed eight smoke alarms and 1 carbon monoxide detector were in good working order.
The kitchen area was sufficiently stocked with at least two days of perishables and seven days of non-perishables.
The facility has an entry station at the front door entering the facility. Upon entry, staff, visitors, and clients who are returning from an outing are required to sign-in and have a temperature screening. All documentation is kept in a binder in the locked staff office. Documentation is filed on a regular basis.
PPE gear, hand sanitizer, disinfecting wipes, disinfecting spray, gloves, masks, and thermometers, and backup PPE are kept in the garage and in the kitchen area. A backup supply of PPE gear is kept in the garage.
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: 10/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2022
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: MESA CARE
FACILITY NUMBER: 425801158
VISIT DATE: 10/18/2022
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 Cleaning agents are kept in a cabinet in the garage. Medications are kept in two cabinets in the facility’s laundry room. At 3:39 pm, LPA Kontilis observed one of the two medication cabinets unlocked at the time of the visit. The facility maintains a comfortable temperature. First aid supplies were observed to be in good order.
Residents participate at will in music activities, puzzles, games, and visits to local eateries.
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. LPAs observed the kitchen cabinets, refrigerator, stove, and counters are clean.
There are six private bedrooms and an extra bedroom. Bedrooms #5 and #7 have a private bathroom. There are two bathrooms off the facility hallway.
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 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.
Please continue to 809-C, Pg 3.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2022
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: MESA CARE
FACILITY NUMBER: 425801158
VISIT DATE: 10/18/2022
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At 2:52 pm, LPAs observed Staff 1 (S1) in the kitchen of the facility not wearing a mask. LPAs observed S1 leave the kitchen area and enter into a private bedroom. LPAs observed S1 exit the private bedroom and walk through the common area and leave the facility, S1 was not wearing a mask when they exited the facility.LPAs requested S1 put on a mask different two times.
At approximately 3:15 pm, LPA Olson observed S1 in the front yard of the facility. LPA Olson inquired as to S1's name and requested identification. S1 provided their California Department of Motor Vehicles Driver's License to LPA Olson.

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. 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: 10/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 10/18/2022 05:59 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: MESA CARE
FACILITY NUMBER: 425801158

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.1(a)(2)
87468.1 (a)(2) Personal Rights of Residents in all Facilities; To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:

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 in that one out of three staff was not wearing a face mask while in the kitchen area and common area in the facility which poses an immediate health, safety and personal rights risk to residents in care.
POC Due Date: 10/19/2022
Plan of Correction
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Administrator agrees to implement mask wearing in the facility immediately; conduct training on mask/infection disease prevention with all staff and provide training records with full name, signatures, dates, and description of training to CCL by 10/19/2022.
Type A
Section Cited
CCR
87465(h)(2)
87465(h)(2) Incidental Medical and Dental Care: (h) The following requirements shall apply to medications which are centrally stored: (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 one out of two medication cabinets located in the laundry room was observed to be unlocked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/19/2022
Plan of Correction
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Administrator agrees to keep medication cabinets locked at all times. POC cleared at time of visit.

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: 10/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4