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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801755
Report Date: 09/18/2024
Date Signed: 09/18/2024 03:34:27 PM


Document Has Been Signed on 09/18/2024 03:34 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
WOODLAND HILLS NORTH, 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: 5DATE:
09/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Timothy Pryko, Administrator and Valerija Bohonko, Assistant AdministratorTIME COMPLETED:
03:30 PM
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On 09/18/2024, Licensing Program Analyst (LPA) Brian Phillips arrived at the facility above to conduct an unscheduled, required inspection evaluation visit. When the LPA arrived, they were greeted by Administrator Timothy Pryko and Assistant Administrator Valerija Bohonko and informed them of the reason for the visit.

The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. This is a Residential Care Facility for the Elderly (RCFE) with an approved fire clearance capacity of six (6) non-ambulatory residents, of which one (1) may be bedridden. This facility has an approved hospice care waiver for four (4) residents in care. The physical plant of the facility consists of a main entrance area, living room/dining room, kitchen area, laundry area, six (6) resident bedrooms, seven (7) restrooms, and a converted garage Staff area. The facility has an outdoor area completely fenced/wall/gated in. This outside area can be utilized for outdoor activities/outdoor visitations and has an outdoor patio area with furniture and shade.

The LPA inspected the food service area and observed that knives/sharp instruments are stored in locked drawers inaccessible to clients. All appliances were in operable condition and looked clean/in good repair. Appliances such as microwaves, refrigerators, stoves, etc. are clean and operating properly. Food utensils, dishes, glasses, etc. are clean and in good repair with no cracks or chips. Furniture is room/resident appropriate, clean and in good repair. All rooms are appropriately furnished for their intended use such as bedrooms, dining rooms, kitchens, living rooms, etc. Hot water temperature is maintained between 105-120 degrees Fahrenheit as per Community Care Licensing (CCL) Title 22 regulations. Outdoor activity spaces have shaded areas and furnished for outdoor use. Each resident has an adult bed with a mattress, pad, bedsprings, and pillow, which are clean and in good repair. Each bed is fitted with sheets, pillowcase, blankets, and bedspread that are clean and in good repair. Each resident has adequate dresser and closet space for clothing and other belongings that includes at least two drawers or adequate dresser space. The facility has a sufficient supply of linens to permit weekly changing or more often to always insure clean linens for residents. Equipment/supplies for resident personal hygiene is available and on site. Activity supplies are available for residents. Continued on 809-C

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Brian PhillipsTELEPHONE: (805) 956-1636
LICENSING EVALUATOR SIGNATURE:
DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2024
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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ABUNDANT CARE IV
FACILITY NUMBER: 425801755
VISIT DATE: 09/18/2024
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As the facility has an approved fire clearance for a maximum of six (6) residents, there is no signal system required or observed by LPA. Refrigerators and freezers are maintained at an appropriate temperature Fahrenheit as per Community Care Licensing (CCL) regulations. Food storage and preparation areas, including pantries, cupboards, counters, etc., are clean and appropriate for food preparation. The food service area was clean and sanitary, with covered trashcans and operating ventilation systems. No toxic substances are stored in any food preparation or storage area, and all cleaning supplies for the kitchen are kept in a separate area than the food supplies. There is enough tableware and utensils for all clients living in the facility, and enough equipment for the storage, preparation, and service of food. A locked storage area for central storage of medications is available. Walls, ceilings, floors, carpeting, window screens, and areas around the facility are clean, painted and/or in good repair. There are locked storage area(s) for poisons, toxic, cleaning solutions, disinfectants, etc. Fire extinguishers and smoke detectors operate properly and are serviced annually. Doors and passageways are unobstructed. There are no pools/bodies of water on the physical plant of the facility as observed by LPA aside from a shallow fountain in the backyard area which does not present a hazard to residents. During the inspection, LPA did not observe any firearms that would require trigger locks, locked and inaccessible, or firing pins removed.

At the time of the visit, all common areas/interior rooms of the facility were observed to be appropriately furnished, with all furniture in good condition. There are activity materials in the common areas of the facility in good repair and operating condition. The facility maintained a comfortable temperature in all areas inspected. There is appropriate lighting in all the common areas of the facility. All passageways through the common areas of the facility were free of obstruction, with no changes in incline requiring ramps and/or sturdy hand railings/stair chair accessibility devices. This facility is one (1) story throughout and therefore there are no stairways for clients to utilize. The outdoor backyard area of the facility has unlocked gates on each side of the building, and a small shallow fountain filled with rocks and water observed by LPA. There are two (2) sheds in the backyard/side of the facility, containing cleaning materials and maintenance equipment. Both sheds are locked and were opened for LPA observation.

The outdoor activity space is completely enclosed by fencing and latching gates. The designated laundry area is in a locked addendum/closet area in a hallway of the facility, with the storage of cleaning products locked and inaccessible to clients, away from food products. There was emergency food and water in cabinets in the living room/dining room area of the facility, which was observed to be in good condition. Cleaning supplies, disinfectants, and other items that could pose a danger to clients are kept in areas inaccessible to clients. Continued on 809-C

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Brian PhillipsTELEPHONE: (805) 956-1636
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024
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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ABUNDANT CARE IV
FACILITY NUMBER: 425801755
VISIT DATE: 09/18/2024
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The facility restrooms were sanitized and in operating condition while the LPA toured the facility. There are seven (7) resident restrooms in the facility that included soap, paper towels, required postings, and clean trashcans with closed lids. Six (6) of the restrooms are private resident restrooms in the interior of each resident bedroom, and one (1) restroom is communal in the hallway of the facility. All restrooms were sufficiently stocked with soap, paper towels, and additional supplies; towels and washcloths are not shared. The hot water temperature was measured in the restrooms at the appropriate degrees Fahrenheit as per Title 22 regulations between 105-120 degrees Fahrenheit. There are an adequate number of toilets per residents in the facility. Nightlights are installed as observed by LPA. All toilets and hand washing areas are maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences are available accommodate any physically handicapped residents who need such items. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. There are six (6) designated resident rooms in the facility. Each resident bedroom has a bed/beds, nightstands, and lights and nightstand lamps to provide sufficient lighting. Each closet in all the resident rooms can store or has extra pillows, clean/fresh linens, and appropriate incontinence materials if applicable for any resident. The resident bedrooms are big enough for all beds, furniture, and any resident assisting device a resident might need such as a wheelchair or a walker. Each room has sufficient lighting for each resident. The facility has provisioned to each resident of furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene.

An emergency exiting plan and emergency phone numbers are posted in an appropriate place. A current disaster and mass casualty plan maintained at the facility. First-aid supplies, which include sterile first-aid dressings, bandages, adhesive tapes, scissors, tweezers, thermometer, antiseptic solution, and a current first-aid manual, are maintained. Administrator’s records, employees and resident records are maintained at the facility and available for review by the LPA as employees are hired and residents accepted into the facility. The facility complies with CCL standards for health screening, TB clearance, staff training, criminal background clearance and transfer requests. Admission agreements and needs and services (ANS) plan are maintained for each resident and/or their authorized representative. Resident records are maintained on the facility premises in a secured area. Centrally stored medications are locked in secure locked cabinets in the kitchen area of the facility. The facility administrator meets the qualifications as specified in Title 22 regulations. Administrator has a current RCFE administrators’ certificate that expires on 05/03/2025.

Exit interview conducted with no deficiencies nor citations. Copy of this report provided to facility.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Brian PhillipsTELEPHONE: (805) 956-1636
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024
LIC809 (FAS) - (06/04)
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