425802131-6-11-2024-29-AS-KKOS-D662AF-20240611171328

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425802131
Report Date: 06/11/2024
Date Signed: 06/11/2024 05:15:02 PM

Document Has Been Signed on 06/11/2024 05:15 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:	CASA BEAUMONT		FACILITY NUMBER:	425802131
ADMINISTRATOR:	ANTON ZAMYATIN		FACILITY TYPE:	740
ADDRESS:	571 BEAUMONT WAY		TELEPHONE:	(805) 455-9953
CITY:	GOLETA	STATE: CA	ZIP CODE:	93117
CAPACITY:	6	CENSUS: 6	DATE:	06/11/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:05 PM
MET WITH:	Anton Zamyatin, Administrator		TIME COMPLETED:	05:30 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 required Annual Inspection to the above-named facility. At the time of arrival, there were six (6) residents in care and two (2) staff on duty. Administrator Anton Zamyatin arrived at approximately 1:35 pm. Katerina Zamyatina, Adminsitrator arrived at approximately 2:00 pm. 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. There are three (3) residents currently 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 and Resident’s Rights. LPA inspected the two-story facility for fire safety, personal accommodations, and food service. Two first aid kits were observed to be complete. 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 most recently conducted on 2/12/2024. There are seven (7) dual carbon monoxide detectors/smoke alarms throughout the facility all in good working order. The kitchen area was sufficiently stocked with two-day perishables and seven days of non-perishables. Snacks and beverages are readily available for Residents. LPA observed the kitchen cabinets, refrigerator, stove, and counters are clean. Medications and first aid kits are kept in a locked cabinet in the hallway next to the dining area. Residents participate independently in music entertainment, exercise program, neighborhood walks, and one-on-one socialization among the residents. The front yard consists of walkways, sitting areas, and garden areas. The backyard has a concrete patio, sitting areas, and garden areas. The backyard is conducive for outdoor visitation. The recycling bin, green waste bin, and trash bins are standard bins with flip lids. Chemicals and cleaning supplies are kept in a locked cabinet at the entrance into the facility. Please continue to 809-C.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024

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: CASA BEAUMONT	FACILITY NUMBER: 425802131
	VISIT DATE: 06/11/2024

NARRATIVE

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The kitchen, living room, and dining area are neat and clean. The facility maintains a comfortable temperature. Hallways, bedroom doors, and walls are in good repair.
There are five private bedrooms. Bedroom #1 has a private bathroom and an exit into the backyard. Each bedroom has a bed, a nightstand, and lights and/or nightstand lamps to provide sufficient lighting.
There are two bathrooms each with a shower room located in the hallway with access available to all residents. The bathrooms have secure grab bars and no skid flooring.
All persons associated with the facility have a criminal record clearance and have been properly associated to the facility.
The second floor of the facility is the administrative office where all confidential documents are kept in locked cabinets. The live-in staff room is also located on the second floor and remains locked 24 hours/day.
Co-administrator Anton Zamyatin stated Oleg Nenakhov has been designated as the Co-administrator to assist in administrative duties and responsibilities as well as providing care and supervision to the residents in care.
Medication review revealed unexplainable discrepancies for three medications administered to Resident 1 (R1) as follows: Hydrochorothiazide 25mg short one tablet and Losartan Potassium F/C 100mg short two tablets. Additionally, it is likely that the total quantity of Quetiapine Fumarate 25mg was entered incorrectly on the Centrally Stored Medication Accounting Record (MAR). The medication start date was 4/13/2024 with 180-count upon the start date. During today’s inspection, the inventory count for Quetiapine Fumarate 25mg was 60 tablets remaining in the container and the MAR reflected 236 tablets had been administered since the start date of 4/13/2024. Technical assistance was given at the time of the inspection to include documentation on the MAR if a medication is discarded or if an unusual event occurs involving the accuracy of medications being administered.

The following deficiencies were observed (see LIC809-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code.

Exit interview conducted. Copy of report issued at the time of the visit.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/11/2024 05:15 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: CASA BEAUMONT	FACILITY NUMBER: 425802131
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(c)(2)

87465(c)(2) Incidental Medical and Dental Care: Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above when an unexplainable shortage of two medications were observed; additionally, the record review showed a third medication had an unexplainable discrepancy among the medication start date, the number of medications administered, and the remaining medication count which poses an immediate health, safety, or personal rights risk to persons in care.
	POC Due Date: 06/12/2024
	Plan of Correction
1 2 3 4	Administrators agree to conduct medication training to all staff who are responsible for administering medications including but not limited to description of the training, first and last name of the trainer, first and last names of the trainees, date and duration of the training, and signature page reflecting all those who attended. By 6/12/2024, Administrators agree to notify LPA of the date training will be conducted. Administrators agree to conduct training no later than 6/18/2024.

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: 06/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024

LIC809 (FAS) - (06/04)

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