425801626-1-16-2024-29-AS-KKOS-CZJUPS-20240116144602

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425801626
Report Date: 01/16/2024
Date Signed: 01/16/2024 02:47:01 PM

Document Has Been Signed on 01/16/2024 02:47 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:	CASA SAN MIGUEL		FACILITY NUMBER:	425801626
ADMINISTRATOR:	ANTON ZAMYATIN		FACILITY TYPE:	740
ADDRESS:	1403 SAN MIGUEL AVE.		TELEPHONE:	(805) 963-1214
CITY:	SANTA BARBARA	STATE: CA	ZIP CODE:	93109
CAPACITY:	6	CENSUS: 5	DATE:	01/16/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:55 PM
MET WITH:	Katerina Zamyatina, Administrator		TIME COMPLETED:	03:30 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 required Annual Inspection at the above-named facility. LPA arrived at 12:55 pm and was greeted by Katerina Zamyatina, Administrator and explained the purpose of the visit. At the time of arrival, there were two (2) staff on duty and five (5) residents in care. Co-Administrator Anton Zamyatin arrived at approximately 1:44 pm. Entrance interview conducted. The facility is a one-story Residential Care Facility for the Elderly (RCFE). Currently, there is one resident on hospice and no bedridden residents. 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. 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. There are four fire extinguishers, inspection was current as of 2/22/2023. The carbon monoxide alarm and smoke alarms are hard wired and in good working order. Additionally, the facility has two pull fire alarms. The kitchen area was sufficiently stocked with two-day perishables and seven days of non-perishables. Snacks and beverages are readily available for Residents. Frozen foods are properly wrapped and stored appropriately. LPA observed the kitchen cabinets, refrigerator, stove, and counters are clean. Medications, First Aid kit, and additional first aid supplies are kept in a locked centrally stored cabinet. First aid kit was observed to be complete. Residents participate independently in physical therapy, music entertainment, joyous movement (music and chair exercise), floral arranging, books by Braille, pet therapy including miniature pony therapy, arts and crafts, gardening and outings to parks, restaurants, and other local attractions. 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: 01/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024

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: CASA SAN MIGUEL	FACILITY NUMBER: 425801626
	VISIT DATE: 01/16/2024

NARRATIVE

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The front yard consists of walkways, sitting areas, and garden areas. The backyard has walkways, garden sitting areas, and a gazebo. There are no bodies of water. The recycling bin, green waste bin, and trash bins are standard bins with flip lids. A locked garage is located at the front of the home used for storing supplies.
The kitchen, living room, and dining area are neat and clean. The facility maintains a comfortable temperature.
There are six private bedrooms. Bedrooms #1, 2, 3, and 4 have private-half bathrooms. Each bedroom has a bed, nightstands, and lights and nightstand lamps to provide sufficient lighting.
There are two half baths with hallway access available to all residents. There is one full-size bathroom/shower room utilized for all residents. The bathrooms have secure grab bars and no skid flooring.
Residents’ files were reviewed. LPA noted that on file for each resident was the following: Physician’s Reports, Admission Agreements, Medical Assessments, Identification and Emergency information, Appraisals/Needs Service Plan, and Medication Administration Records (MARs).
All persons associated with the facility have criminal record clearance. Administrator certificate is valid. Staff files reviewed had criminal record statements, health screenings, current first aid certificates, and all required training. All persons associated with the facility have criminal record clearance.

Exit interview conducted. No deficiencies noted. Copy of report 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: 01/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024

LIC809 (FAS) - (06/04)

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