425801981-7-20-2022-29-AS-KKOS-CGHVC2-20220720161821

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425801981
Report Date: 07/20/2022
Date Signed: 07/20/2022 04:18:44 PM

Document Has Been Signed on 07/20/2022 04:18 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:	YOUR HOME, RCFE		FACILITY NUMBER:	425801981
ADMINISTRATOR:	VIKTORIIA ANDREICHENKO		FACILITY TYPE:	740
ADDRESS:	128 SAN RAFAEL AVENUE		TELEPHONE:	(805) 965-3885
CITY:	SANTA BARBARA	STATE: CA	ZIP CODE:	93109
CAPACITY:	6	CENSUS: 5	DATE:	07/20/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:53 PM
MET WITH:	Viktoria, Andreichenko, Administrator		TIME COMPLETED:	03:45 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 Analyst (LPA) Kristin Kontilis conducted an unannounced on-site one-year Infection Control Inspection and Annual visit to the above-named facility. LPA arrived at 12:53 pm and was greeted by Staff 1. Administrator Viktoria Andreichenko arrived at approximately 1:13 pm. At the time of arrival, there were 5 residents in care and 1 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 and a Hospice Waiver for four residents. Currently, there are no residents 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. The facility maintains a comfortable room temperature. First aid kit was observed to be complete. The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, doors, floors and floor coverings were checked. There is one fire extinguisher on the premises last serviced on 6/23/2022. There is a total of one (1) carbon monoxide detector and seven (7) smoke alarms throughout the facility all in good working order. Snacks and beverages are available for residents in care upon request. LPA observed the kitchen cabinets, refrigerator, stove, and counters are clean. Cleaning agents and the toxic chemicals are kept in a locked garage. Medications are kept in a cabinet located in the Administrator’s office. Sharps are kept in a cabinet above the microwave oven located in the kitchen. LPA advised Administrator that although the cabinet is out of reach of most residents, a lock on the cabinet would add additional re-assurance that the sharps are inaccessible to residents in care. Administrator placed a lock on the cabinet during LPA's visit. 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: 07/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022

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: YOUR HOME, RCFE	FACILITY NUMBER: 425801981
	VISIT DATE: 07/20/2022

NARRATIVE

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The backyard has a deck with table and chairs, a gazebo, raised garden area and a ramp for access throughout the yard. The backyard is conducive for outdoor visitations. The front yard has garden areas and access as the main entrance into the facility. The recycling bin, green waste bin, and trash bins are standard bins with flip lids.
The facility has three (3) shared bedrooms for a capacity of six residents. All of the bedrooms are furnished with lights and nightstand lamps to provide sufficient lighting.
Bedroom #1 and 2 utilize a bathroom off the hallway. Bedroom #3 has a private bathroom utilized only by the residents who reside in Bedroom #3.
All persons associated with the facility have a criminal background clearance.

Exit interview conducted. No citations issued at this time. Copy of report 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: 07/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022

LIC809 (FAS) - (06/04)

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