425850018-5-19-2023-29-AS-KKOS-CRYTLR-20230519144959

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425850018
Report Date: 05/19/2023
Date Signed: 05/19/2023 02:50:09 PM

Document Has Been Signed on 05/19/2023 02:50 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 SALISBURY		FACILITY NUMBER:	425850018
ADMINISTRATOR:	ZAMYATINA, EKATERINA		FACILITY TYPE:	740
ADDRESS:	264 SALISBURY AVE		TELEPHONE:	(805) 455-9953
CITY:	GOLETA	STATE: CA	ZIP CODE:	93117
CAPACITY:	6	CENSUS: 6	DATE:	05/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Katerina Zamyatina, Administrator; Anton Zamyatin, Administrator		TIME COMPLETED:	03:30 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 Annual Required visit and inspection of the facility. LPA arrived at 11:00 am. At the time of arrival, there were two (2) staff on duty and six (6) residents in care. Administrator Katerina Zamyatina arrived at approximately 11:15 am. Co-Administrator Anton Zamyatin arrived at approximately 11:40 am. Entrance interview conducted: The facility is a one-story Residential Care Facility for the Elderly (RCFE). The facility has a dementia waiver for six residents; a waiver for six hospice residents; and a fire clearance for six bedridden residents. Currently, there is one resident on hospice and there are no residents who are bedridden 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, bill of rights and Resident’s Rights. LPA inspected the one-story facility for fire safety, personal accommodations, and food service. 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. There are three fire extinguishers, inspection was current as of 2/7/2023. The carbon monoxide alarm and smoke alarms are hard wired and in good working order. Additionally, the facility has one fire pull alarm. The kitchen area was sufficiently stocked with two-day perishables and seven days of non-perishables. Snacks and beverages are readily available for Residents. Frozen foods are properly wrapped and stored appropriately. LPA observed the kitchen cabinets, refrigerator, stove, and counters are clean. Medications, First Aid kit, and additional first aid supplies are kept in a locked centrally stored cabinet. First aid kit was observed to be complete. Residents participate independently in music entertainment, games, an interactive cat, physical movement, gardening, baking, and outings to parks, restaurants, religious actiities, and other local attractions. 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: 05/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

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 SALISBURY	FACILITY NUMBER: 425850018
	VISIT DATE: 05/19/2023

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
26
27
28
29
30
31
32

The front yard consists of a walkway, sitting area, and a lawn and garden area. The backyard consists of a large, stamped concrete “flagstone” style surface with sitting areas with tables, chairs, and umbrellas. A retaining wall surrounds the backyard that encloses plants and trees. The backyard is conducive to exercise activities and visitations with family and friends. There are no bodies of water. The recycling bin, green waste bin, and trash bins are standard bins with flip lids. A locked garage is located on the north side of the home used for storing personnel records, residents’ records, medical supplies, washing machine, dryer, cleaning supplies, and office supplies. The garage is inaccessible to residents in care.
The kitchen, living room, and dining area are neat and clean. The facility maintains a comfortable temperature.
There are six private bedrooms. Bedrooms #1-5 have private bathrooms. Bedroom 6 has a shared bathroom off the hallway. The bathrooms have secure grab bars and no skid flooring.
Each bedroom has a bed, night stand, and lights and night stand lamps to provide sufficient lighting as well as access into the backyard area.
All persons associated with the facility have criminal record clearance. Administrator certificate is valid.

Exit interview conducted. No citations issued. A copy of this 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: 05/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2