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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850070
Report Date: 11/19/2021
Date Signed: 11/19/2021 03:19:29 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 RDTELEPHONE:
(805) 403-7455
CITY:SANTA BARBARASTATE: CAZIP CODE:
93109
CAPACITY:6CENSUS: 4DATE:
11/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Administrator Viktoriia AndreichenkoTIME COMPLETED:
11:35 AM
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On 11/19/21 at 9:35 AM, Licensing Program Analyst (LPA) Toan Luong arrived at the facility and contacted Administrator Viktoriia Andreichenko via telephone to perform a facility risk assessment. LPA conducted an unannounced on-site One Year Infectious Control Annual visit to the facility. LPA met with Administrator Viktoriia Andreichenko and explained the purpose of the visit.

Administrator took LPA on a physical plant tour of the facility. The facility has submitted a mitigation plan to the department.

The facility is a Residential Care Facility for the Elderly. During the facility tour LPA observed Covid-19 signs posted throughout the facility, but CDSS PINs were not posted. Administrator informed LPA that resident's family member have PINs emailed to them. LPA advise having PINs readily accessible to residents, visitors, and staff. One room has beds not six feet apart. Facility has only one resident residing in the room to mitigate the spread of Covid-19.

LPA reviewed the Annual Mitigation Inspection Control Tool Module. Module was addressed with administrator to satisfaction.

Exit interview was conducted. No deficiencies were cited. Report emailed to administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Toan LuongTELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021
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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