425801755-8-23-2023-29-AS-KKOS-CUYVBL-20230823161742

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425801755
Report Date: 08/23/2023
Date Signed: 08/23/2023 04:17:53 PM

Document Has Been Signed on 08/23/2023 04:17 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 IV		FACILITY NUMBER:	425801755
ADMINISTRATOR:	TIMOTHY PRYKO		FACILITY TYPE:	740
ADDRESS:	5421 BERKELEY ROAD		TELEPHONE:	(805) 689-6900
CITY:	SANTA BARBARA	STATE: CA	ZIP CODE:	93111
CAPACITY:	6	CENSUS: 6	DATE:	08/23/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Timothy Pryko, Administrator		TIME COMPLETED:	04:45 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 Analysts (LPAs) Darlene Chavez and Kristin Kontilis conducted an unannounced required Annual Inspection at the facility. The facility is a one-story home which is licensed as a Residential Care Facility for the Elderly (RCFE) with a dementia diagnosis. The facility has been approved for a hospice waiver for 4 residents and has a fire clearance for 6 non-ambulatory residents, one of which can be a bedridden resident. Upon arrival, there were 5 residents in care and 2 staff on duty. One resident was away from the facility. Currently there are 6 residents residing in the facility with 1 resident on hospice. Administrator Timothy Pryko arrived at approximately 10:23 am. LPAs explained the purpose of the visit. Entrance interview conducted. 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, Resident’s Rights, Non-discrimination statement, Infection Control Plan, and Emergency and Disaster Plan. LPAs inspected the facility for fire safety, personal accommodations, and food service. First aid kit was observed to be complete. The facility has 6 private bedrooms each with a private bathroom 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. 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. Fire inspection was conducted on 6/15/2023. The carbon monoxide alarm and smoke alarms are in good working order. Medications are kept in a locked centrally stored cabinet. 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. 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: 08/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023

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 IV	FACILITY NUMBER: 425801755
	VISIT DATE: 08/23/2023

NARRATIVE

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According to the facility sketch used for the fire clearance, Exit #10 located on the east side of the facility is shown as a perimeter gate to exit the property in case of an emergency. Not shown on the facility sketch is a second perimeter gate on the east side leading from the backyard (south of facility). The second perimeter gate is locked from the north side making it inaccessible for residents/staff to exit in the case of an emergency. Noted on the gate is a sign that reads "Keep gate locked at all times."
The facility sketch shows Exit #11 is a wrought iron gate with a combination lock located on the inside of the gate with signage stating "Keep gate locked at all times."
LPAs observed the Emergency and Disaster drill logs do not specify the type of drill performed at the time of the drill. LPAs advised Administrator Pryko that all future drills need to state the specific drill being conducted or provide more specific information as to the description of what was covered during the drill.
LPAs observed an oxygen tank in the facility with an "oxygen in use" sign on the door of Resident 1 (R1). There was no "oxygen in use" sign posted on the front door entering into the facility.
The backyard has a covered patio with outdoor furniture. There is a cement fountain located in the backyard. The fountain is filled with water and rocks.
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.
From 10:33 am to 10:40 am, water temperatures were measured as 111.7 degrees Fahrenheit (F) in the kitchen, Bathroom #1 measured at 108.0 (F), and Bedroom #4 measured at 108.6 degrees (F).
Residents participate at will in activities such as games, drawing, playing piano, scenic drives, and special celebrations.
Staff records were reviewed. Staff training and required documents are in good order. All staff have received a criminal background check 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. A copy of this report was issued during the visit.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/23/2023 04:17 PM - 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 IV	FACILITY NUMBER: 425801755
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations and interviews conducted, the licensee did not comply with the regulation above when one outside perimeter gate was locked and another gate had a latch on the external side of the gate restricting residents/staff from exiting the property in the event of an emergency. Signage posted on each gate stated, “Keep gate locked at all times.” This poses an immediate health and safety risk to residents in care.
	POC Due Date: 08/24/2023
	Plan of Correction
1 2 3 4	Plan of Correction: Administrator removed the lock from the gate. Administrator agrees to reverse the latch on the gate to make it accessible to residents/staff by the POC due date (8/24/2023).

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: 08/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023

LIC809 (FAS) - (06/04)

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