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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801755
Report Date: 09/23/2022
Date Signed: 09/23/2022 04:29:45 PM


Document Has Been Signed on 09/23/2022 04:29 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:ABUNDANT CARE IVFACILITY NUMBER:
425801755
ADMINISTRATOR:TIMOTHY PRYKOFACILITY TYPE:
740
ADDRESS:5421 BERKELEY ROADTELEPHONE:
(805) 689-6900
CITY:SANTA BARBARASTATE: CAZIP CODE:
93111
CAPACITY:6CENSUS: 6DATE:
09/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Timothy Pryko, AdministratorTIME COMPLETED:
01:40 PM
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Licensing Program Analysts (LPAs) Diego Cortez and Kristin Kontilis conducted an unannounced Annual Required visit and inspection of the facility. LPAs arrived at 12:10 pm and were greeted by Staff 1 (S1). Upon arrival, there was one staff on duty and five residents in care. One resident was on an outing with a family member. Timothy Pryko arrived at approximately 12:27 pm. LPAs explained the purpose of the visit.

Entrance interview conducted.
There are currently 6 residents residing in the facility. The facility is home to residents with a dementia diagnosis. There are currently two (2) residents on hospice.
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. 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 conducted on 9/11/2022. The carbon monoxide alarm and smoke alarms are in good working order. Medications are kept in a locked centrally stored cabinet.
The backyard has a covered patio with outdoor furniture. There are no bodies of water. The recycling bin, green waste bin, and trash bins are standard bins with flip lids. A locked private staff room is located in the main part of the house near the front entrance.
The living room and dining area are neat and clean. The facility maintains a comfortable temperature at 74.0 degrees Fahrenheit (F). Hallways, bedroom doors and walls are in good repair.
The facility has 6 private bedrooms and private bathrooms for 6 residents. Each resident’s room is furnished with overhead lights to provide sufficient lighting, a night stand, and a bed. The bathrooms have secure grab bars and no skid flooring. 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: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2022
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 2


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 IV
FACILITY NUMBER: 425801755
VISIT DATE: 09/23/2022
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 The kitchen, living room, and dining area are neat and clean. The facility maintains a comfortable room temperature. Hallways, bedroom doors, and walls are in good repair.
The facility has multiple areas spaced to accommodate as much space as possible for social distancing. The staff screen residents for symptoms and temperature at least once a day and documentation is kept on file. Increased monitoring is conducted if any change of condition are noted or any residents are showing any signs, symptoms or a temperature. Signs are posted on the front door, entry area regarding Covid-19.
Staff ensure residents have a mask when leaving the facility on outings into the community. All staff wear face coverings in the facility and when on outings with residents. Facility has areas for visiting inside and outside. The facility also offers virtual and telephone communications to all residents in care. Staff, Residents, and visitors are informed of the facilities infection control policies. New residents and staff will be tested and negative results received before working or residing in the facility. The facility has procedures and plans for screening, isolation, testing, when to call 911 and notifying all responsible parties and agencies when needed.
The facility has multiple areas spaced to accommodate as much space as possible for social distancing. The staff screen residents for symptoms and temperature at least once a day and documentation is kept on file. Increased monitoring is conducted if any change of condition are noted or any residents are showing any signs, symptoms or a temperature. Signs are posted on the front door, entry area regarding Covid-19.
Staff ensure residents have a mask when leaving the facility on outings into the community. All staff wear face coverings in the facility and when on outings with residents. Facility has areas for visiting inside and outside. The facility also offers virtual and telephone communications to all residents in care. Staff, Residents, and visitors are informed of the facilities infection control policies. New residents and staff will be tested and negative results received before working or residing in the facility. The facility has procedures and plans for screening, isolation, testing, when to call 911 and notifying all responsible parties and agencies when needed.
LPAs confirmed all staff have received a criminal background clearance and are properly associated to the facility.

Exit interview conducted. No deficiencies cited. Report issued via email.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022
LIC809 (FAS) - (06/04)
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