425801580-8-4-2022-29-AS-KKOS-CGYKS2-20220804080850

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425801580
Report Date: 08/03/2022
Date Signed: 08/04/2022 08:09:36 AM

Document Has Been Signed on 08/04/2022 08:09 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 III		FACILITY NUMBER:	425801580
ADMINISTRATOR:	DANIEL BOND		FACILITY TYPE:	740
ADDRESS:	4589 AUHAY DRIVE		TELEPHONE:	(805) 845-8490
CITY:	SANTA BARBARA	STATE: CA	ZIP CODE:	93110
CAPACITY:	6	CENSUS: 6	DATE:	08/03/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:17 PM
MET WITH:	Lidia Kravchuk, Co-Administrator		TIME COMPLETED:	02:55 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 on-site one-year Infection Control Inspection visit to the above-named facility. LPA arrived at 12:17 pm and was greeted by Staff 1 (S1). Administrator Lidia Kravchuk arrived at approximately 12:32 pm. At the time of arrival, there were 6 residents in care and 2 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: 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. 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 eight (8) 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 Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022

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 III	FACILITY NUMBER: 425801580
	VISIT DATE: 08/03/2022

NARRATIVE

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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.
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.
At 12:21 pm LPA observed Staff 1 (S1) not wearing a mask while in the facility. S1 put on a mask per LPA’s request. At 12:23 pm, LPA observed Staff 2 (S2) not wearing a mask while in the facility. S2 obtained a mask from the kitchen area and complied with LPA’s request.
All persons associated with the facility have a criminal record clearance 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. Copy of this report and Appeal Rights issued via email.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/04/2022 08:09 AM - 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 III	FACILITY NUMBER: 425801580
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Deficiency Dismissed

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 is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA’s observation, the licensee did not comply with regulation above when Staff 1 and Staff 2 were present in the facility without wearing masks which poses an immediate health, safety, and personal rights risk to residents in care.
	POC Due Date: 08/05/2022
	Plan of Correction
1 2 3 4	Licensee agrees to schedule infection control training, including mask requirements, for all staff by 8/5/2022. Training will be completed and provide proof of training with staff signatures by 8/5/2022

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: 08/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022

LIC809 (FAS) - (06/04)

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