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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801580
Report Date: 07/12/2023
Date Signed: 07/13/2023 08:10:40 AM


Document Has Been Signed on 07/13/2023 08:10 AM - 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 IIIFACILITY NUMBER:
425801580
ADMINISTRATOR:DANIEL BONDFACILITY TYPE:
740
ADDRESS:4589 AUHAY DRIVETELEPHONE:
(805) 845-8490
CITY:SANTA BARBARASTATE: CAZIP CODE:
93110
CAPACITY:6CENSUS: 6DATE:
07/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:47 AM
MET WITH:Lidia Kravchuk, Administrator TIME COMPLETED:
03:45 PM
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Licensing Program Analysts (LPAs) Darlene Chavez and Kristin Kontilis conducted an unannounced required annual inspection to the above-named facility. LPA arrived at 9:47 am and was greeted by Staff 1 (S1). Administrator Lidia Kravchuk arrived at approximately 10:15 am. Administrator Daniel Bond arrived at approximately 10:35 am. At the time of arrival, there were 6 residents in care and 3 staff on duty.
The facility is a Residential Care Facility for the Elderly (RCFE) and is home to non-ambulatory residents with a dementia diagnosis. There is one resident currently on hospice.
Entrance interview conducted:
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 most recently conducted on 7/1/2023. There are approximately six (6) hard-wired dual carbon monoxide detectors/smoke alarms throughout the facility. The alarms will alert the local fire department when activated.
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.
Medications are kept in locked cabinets in the kitchen area. A fire extinguisher and First Aid kit are kept in the hallway at the rear entrance into the facility.
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: 07/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2023
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 III
FACILITY NUMBER: 425801580
VISIT DATE: 07/12/2023
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Residents participate independently in games, puzzles, coloring, and corn hole toss.
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. Chemicals and cleaning supplies are kept in a locked cabinet under the kitchen sink and in the hallway.
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.
All persons associated with the facility have a criminal record clearance and have been properly associated to the facility.
LPAs reviewed five out of six residents’ records. All records were found to be in good order.
Staff records were checked for expired and/or missing certificates and clearances: At approximately 12:15 pm, LPAs conducted a file review of five (5) staff for criminal record clearances/associations and current First Aid. The Administrator file was reviewed for current First Aid, fingerprint clearance, and administrator certificate. Per Administrator Kravchuk, hospice training sign-in sheets for 1/27/2023, 1/31/2023, 6/8/2023, and 6/12/2023 were photocopied and attendees did not sign each time they attended training. Licensee will ensure original signatures are obtained from each attendee for each training. Technical violation issued. Training sign-in sheets for 1/31/2023 and 6/12/2023 did not include the quantity of hours trained on each element. Licensee will ensure that the quantity of time trained on each topic is recorded on the training record. Technical violation issued.

Exit interview conducted. Copy of this report and Advisory Notes - Technical Violations issued at the time of the inspection.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2023
LIC809 (FAS) - (06/04)
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