425801158-10-8-2024-29-AS-KKOS-D9UTPA-20241008145400

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425801158
Report Date: 10/08/2024
Date Signed: 10/08/2024 02:54:09 PM

Document Has Been Signed on 10/08/2024 02:54 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 CARE		FACILITY NUMBER:	425801158
ADMINISTRATOR:	VALENTYNA POLUNETS		FACILITY TYPE:	740
ADDRESS:	2424 CALLE SORIA		TELEPHONE:	(805) 965-2428
CITY:	SANTA BARBARA	STATE: CA	ZIP CODE:	93109
CAPACITY:	6	CENSUS: 6	DATE:	10/08/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Valentyna Polunets, Administrator		TIME COMPLETED:	02:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced Inspection of the above-named facility. Kelly Burley, Licensing Program Manager accompanied LPA during the visit. LPM and LPA were greeted by Staff 1 (S1). Alex Polunets arrived approximately 10:12 am. LPA explained the purpose of the visit. At the time of arrival, there was one staff on duty and six residents in care. The facility is a Residential Care Facility for the Elderly (RCFE) The facility accepts residents with a dementia diagnosis; has a hospice care waiver for four residents; and a fire clearance for six non-ambulatory residents, of which two (2) can be bedridden. Currently there are three (3) residents on hospice residing in the facility. Entrance interview conducted. The facility is a one-story facility located in a residential area. LPM and LPA observed the required posting of the complaint poster and Resident’s Rights. The one-story facility was inspected 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. LPA observed the fire inspection was last conducted on 8/28/2024. LPA observed eight smoke alarms and 1 carbon monoxide detector were in good working order. Entrance into the facility leads into the common area and the dining area. The kitchen cabinets, refrigerator, stove, and counters are clean. The facility is sufficiently stocked with at least two days of perishables and seven days of non-perishables. Snacks and beverages are available for residents in care upon request. Sharps are kept in the laundry room. There are six private bedrooms and one extra bedroom. Bedrooms #5 and #7 have a private bathroom. There is one bathroom off the facility hallway available to all residents in care. Cleaning agents are kept in a cabinet in the garage. Medications are kept in two cabinets in the facility’s laundry room. First aid supplies were observed to be in good order. Please continue to 809-C, Pg 2.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024

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 1

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: 10/08/2024

NARRATIVE

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Residents participate at will in music activities, puzzles, and games.
From 9:31 AM through 11:35 AM, LPA intermittently interviewed residents in care.
From 1:00 PM through 1:10 PM, LPM and LPA interviewed Administrator Alex Polunets.
The backyard has a paved patio with a table and chairs with an umbrella, sitting area, and raised garden areas. The backyard is conducive for outdoor visitations. The front yard has garden areas and is access into the main entrance of the facility. The recycling bin, green waste bin, and trash bins are standard bins with flip lids.
The following deficiencies were observed:
<At 9:33 AM, upon entering the facility, LPM and LPA observed S1 on duty providing care to six residents. LPM and LPA determined that S1 has a background clearance however is not properly associated to the facility.
<At 9:37 AM, LPM observed a tray on the kitchen counter with five empty medication cups and one medication cup with 4 white medications, one yellow medication and one red medication.
<At 9:37 AM, LPM observed the front right stove burner on a "low-medium" flame visibly burning and unattended by staff. A verbal warning was discussed with Administrator Alex Polunets.
<At 10:29 AM, LPA noted the residents' bathroom off the hallway water temperature was measured at 127.0 degrees Fahrenheit (F). LPA noted that at the time the water temperature was measured, the temperature continued to rise.
<At 10:36 AM, LPA noted the private shared bathroom between Bedrooms #5 and #7, the water temperature was measured at 128.3 degrees F. LPA noted that at the time the water temperature was measured, the temperature continued to rise.
<At 11:20 AM, LPM reviewed medication records for two residents and noted facility's Centrally Stored Medication Record is not properly completed.

Due to time restraints, LPA will return at a later date to continue the inspection.

The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in additional civil penalties.

Exit interview conducted. A copy of the report and appeal rights issued at the time of the visit.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024

LIC809 (FAS) - (06/04)

Page: 1 of 1

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: 10/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(2)

87355(e)(2) Criminal Record Clearance. 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: Request a transfer of a criminal record clearance as specified in Section 87355(c). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interview, the licensee did not comply with the section cited above when S1 was present and working in the facility without being associated, which posed an immediate safety risk to residents in care. CIVIL PENALTY ISSUED.
	POC Due Date: 10/09/2024
	Plan of Correction
1 2 3 4	Licensee agrees to submit paperwork to associate S1 to the facility by 10/9/2024. S1 may not work in the facility until they are associated.

Type A

Section Cited

CCR

87465(h)(2)

87465(h)(2) Incidental Medical and Dental Care. 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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above when medications were left out unattended in the kitchen, which posed an immediate safety risk to residents in care.
	POC Due Date: 10/09/2024
	Plan of Correction
1 2 3 4	Licensee put the medications away during visit until they were provided to the resident. Licensee agrees to train staff on locking medications and provide proof of training by 10/9/2024.

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	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024

LIC809 (FAS) - (06/04)

Page: 1 of 1

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: 10/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(6)

87465(h)(6) Incidental Medical and Dental Care. The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes…This requirement was not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interview, the licensee did not comply with the section cited above when centrally stored records were not available for at least 2 residents, which posed an immediate health and safety risk to residents in care.
	POC Due Date: 10/11/2024
	Plan of Correction
1 2 3 4	Licensee agrees to complete centrally stored medication records for each resident by 10/11/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024

LIC809 (FAS) - (06/04)

Page: 1 of 1

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: 10/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

87303(e)(2) Maintenance and Operation. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to…not more than 120 degree F (49 degree C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above when water was measured to be above 120, which posed an immediate health and safety risk to residents in care.
	POC Due Date: 10/15/2024
	Plan of Correction
1 2 3 4	Licensee turned down the water heater temperature during visit. Licensee agrees to keep a daily water temperature log for one week and submit to CCL by 10/15/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024

LIC809 (FAS) - (06/04)

Page: 1 of 1