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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850070
Report Date: 11/09/2020
Date Signed: 11/09/2020 02:15:04 PM

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 MOUNTAIN VIEWFACILITY NUMBER:
425850070
ADMINISTRATOR:ANDREICHENKO, VIKTORIIAFACILITY TYPE:
740
ADDRESS:1260 MOUNTAIN VIEW ROADTELEPHONE:
(805) 403-7455
CITY:SANTA BARBARASTATE: CAZIP CODE:
93109
CAPACITY:6CENSUS: 0DATE:
11/09/2020
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Viktoria Andreichenko, AdministratorTIME COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) Kristin Kontilis conducted an announced pre-licensing visit to the facility. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s visit was conducted telephonically with Viktoriia Andreichenko, Administrator, and Irena Obyedkova, Co-Administrator. The facility is a one-story home which will be licensed as a Residential Care Facility for the Elderly (RCFE).

Interview Conducted:
The facility has fire clearance for one bedridden resident and five (5) non-ambulatory residents and consists of a living room, dining area, kitchen, two individual bedrooms, two shared bedrooms and two bathrooms. Each bathroom has a sink, commode, and showers with grab bars.
Upon entrance of the residence, there is a walkway leading to the front door, garden areas, and a large covered fenced patio that surrounds the facility. The backyard area has an outdoor utility kitchen. The facility has a covered carport. There are two fountains with locked fencing surrounding the fountains. The fountains are inaccessible to residents in care.
First aid, emergency supplies, and other supplies are kept in locked cabinets of the outdoor kitchen.
The entrance into the residence leads into the living and dining area. The kitchen consists of a refrigerator, microwave, sink, stove and oven, dishwasher, and a bread-maker. Trash and recycling bins are kept in a pullout drawer. All required CCL posters and signage are posted near the dining area. Personnel files, Residents’ files, and medications will be kept in locked kitchen cabinets and inaccessible to residents in care. Sharps will be kept in a locked kitchen drawer and inaccessible to residents in care. Perishable foods for 2 days and non-perishable foods for 7 days will be kept on hand for the residents.
The living room and dining area are furnished with adequate furnishings to sustain a capacity of six residents.

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: 11/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2020
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 MOUNTAIN VIEW
FACILITY NUMBER: 425850070
VISIT DATE: 11/09/2020
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Bedrooms #1 and #2 are private rooms with an exit/entrance door leading to the outdoor areas. Bedroom #3 and Bedroom #4 are shared bedrooms with a large sliding door leading to the backyard patio. The exit/entrance door in Bedroom #4 will mainly be used for emergency purposes only. All bedroom exit/entrance doors have a properly functioning egress alarm system. Exit signs are posted throughout the facility above doorways leading outside the facility.
Each resident’s bedroom has a bed, mattress, nightstand, chair, dresser, and closet. Overhead lighting and lamps on the nightstands provide sufficient lighting in each bedroom. Hallways have adjustable skylights.
The laundry area and storage area for cleaning agents and chemicals is located off the outdoor kitchen area. The solar generating system will last a minimum of 48 hours. The grey water system is used to water the foliage areas without chemicals.
The backyard consists of a covered, fenced, enclosed patio area with chairs, tables, and umbrellas. The patio has built in garden planters and walkways. The trash, recycling, and green waste cans are standardized cans. Each side of the residence has locked gates that are inaccessible to residents in care. A locked shed is located outside the facility with garden supplies and miscellaneous equipment and tools.
There is a dual carbon monoxide detector and smoke alarm system in the kitchen. Ten (10) smoke detectors are hard-wired with a battery backup located throughout the facility. There is a smoke detector in each bedroom, the hallways, kitchen, and in the living room.
There are three fire extinguishers that were serviced on 11/6/2020. The fire extinguishers are located in living room near the fireplace, kitchen, and laundry room.
The water temperature from the sink faucet in Bathroom #1 was measured at 114.0 degrees Fahrenheit (F) at 12:18 pm. The sink faucet in Bathroom #2 was measured at 112 degrees F at 12:21 pm. Each bathroom has grab bars and non-skid flooring and mats.
The facility maintains a comfortable temperature of approximately 67.6 degrees F measured at 12:22 pm. Residents’ records, personnel documents and records of confidentiality are kept in a locked closet located in the kitchen area.
Residents will participate in various activities based on their individual interests and preferences, including leisure reading, keeping journals, playing games (Dominoes, Bingo, and many others). Zoom classes will provide dancing, music, and singing. Outdoor activities, when permitted, will include gardening, pet therapy, exercise, musical activities, dancing, visitors from community organizations, arts and crafts, games, seasonal celebrations, and excursions to local shopping areas and eateries.Per LPA's observation, physical plant is compliant to Title 22 Regulations at this time.
LPA concluded the inspection. A copy of this report will be issued via email.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2020
LIC809 (FAS) - (06/04)
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