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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801981
Report Date: 05/29/2024
Date Signed: 06/06/2024 04:44:54 PM


Document Has Been Signed on 06/06/2024 04:44 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, RCFEFACILITY NUMBER:
425801981
ADMINISTRATOR:VIKTORIIA ANDREICHENKOFACILITY TYPE:
740
ADDRESS:128 SAN RAFAEL AVENUETELEPHONE:
(805) 965-3885
CITY:SANTA BARBARASTATE: CAZIP CODE:
93109
CAPACITY:6CENSUS: 4DATE:
05/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Viktoriia Andreichenko, AdministratorTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced Annual Required visit and inspection of the facility. At the time of arrival, there were four (4) residents in care, one (1) staff on duty and Administrator Viktoriia Andreichenko was on duty.

Entrance interview conducted:
LPA explained the purpose of the visit. The facility is a one-story Residential Care Facility for the Elderly (RCFE). The facility accepts residents with a dementia diagnosis; has hospice care waiver for four residents; and a fire clearance for six non-ambulatory residents. Currently there is one resident on hospice residing in the facility.
A tour of the physical environment and accommodations were assessed, and the following was noted: LPA observed the required posting of the complaint poster 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 5/22/2024. There is a total of one (1) carbon monoxide detector and seven (7) smoke alarms throughout the facility all in good working order.
Residents participate at-will in activities including exercising, walking around the facility grounds and the neighborhood, music activities, and dance performances.
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.

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: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024
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: YOUR HOME, RCFE
FACILITY NUMBER: 425801981
VISIT DATE: 05/29/2024
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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.
Residents records and personnel records were reviewed and found to be in good order.
All persons associated with the facility have a criminal background clearance.
LPA observed a sufficient amount of perishables for two days and non-perishables for seven days.

Exit interview conducted. No citations issued at this time. Copy of report issued at the time of the visit.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024
LIC809 (FAS) - (06/04)
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