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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850070
Report Date: 11/22/2022
Date Signed: 11/28/2022 08:49:00 AM


Document Has Been Signed on 11/28/2022 08:49 AM - 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 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: DATE:
11/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Viktoria Andreichenko, AdministratorTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced on-site one-year Infection Control Inspection and Annual visit to the above-named facility. LPA arrived at 1:55 pm and was greeted by Staff 1. Administrator Viktoria Andreichenko arrived at approximately 2:14 pm. At the time of arrival, there were 5 residents in care and 1 staff on duty.
A Mitigation Plan has been submitted to CCLD. 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 and a Hospice Waiver for four residents. Currently, there are no residents 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, bill of rights 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.
The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, doors, floors and floor coverings were checked. There are two fire extinguishers on the premises last serviced on 11/18/2022. There is a total of one (1) carbon monoxide detector and ten (10) smoke alarms throughout the facility all in good working order.
The kitchen is equipped with a stove/oven, refrigerator, dishwasher, microwave, coffee pot, and a toaster oven.
Snacks and beverages are available for residents in care upon request. LPA observed the kitchen area and dining areas to be clean. Cleaning agents and the toxic chemicals are kept in locked supply cabinet located in the outdoor laundry room.
Medications are kept in a locked cabinet in the kitchen area. First aid kit and additional first aid supplies are kept in a locked cabinet in the outdoor area of the back deck.
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: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2022
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: 11/22/2022
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 If any suspected or confirmed cases of Covid-19 are found in the facility a staff will be assigned to only work with those quarantined/isolated individuals and will not work with other negative individuals until cleared by Health Department. Staff will use full PPE with N95 masks and face shields when dealing with any pending or confirmed cases of COVID-19. Precautionary Droplet signs will be posted on any room with quarantine or isolated individuals.
PPE supplies will be located immediately outside those rooms when required. Facility has a 30-day supply of PPE on hand. Facility has plans for delivering medications and meals to any quarantined/isolation resident room.
The facility has proper cleaning and disinfectant sprays. Facility Administrator has a plan in place for when and whom to notify in an outbreak or other emergencies. Administrator will keep a line list of all vaccinated and tested staff/residents in care with dates/results.
Facility has conducted training an infection prevention, symptoms, transmission and PPE use. Facility has non-punitive sick leave polices for staff. Staff who have a respiratory illness are requested to stay home and not report to work.
The backyard is a deck with an outdoor kitchen, table and chairs, and a raised garden area. The backyard is conducive for outdoor visitations. The front yard a steep driveway that leads to the main entrance of the facility. The recycling bin, green waste bin, and trash bins are standard bins with flip lids.
Activities have been modified to individuals or small groups with social distancing. Residents' medication is delivered in 30-day supplies to the facility. The facility ensures proper cleaning is done on frequently touched surfaces and between any individuals sharing of space or items.
Sinks were well stocked with soap, paper towels and hand washing signs. Staff and resident records are kept in the locked staff office. Facility observes guidance changes and the most up-to-date guidance from CCL-PINS, CDC, CDPH, and local health departments should be followed to remain in compliance. The most stringent orders should be followed by any of these agencies. Administrator Certificate is valid.
At approximately 1:55, LPA observed Staff 1 (S1) was not wearing a mask when LPA arrived into the facility. LPA requested S1 to put on a mask. S1 secured a mask from a cabinet and complied with LPA’s request.
Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 809-D).

Exit interview conducted. Copy of report and appeal rights issued via email.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/28/2022 08:49 AM - 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 MOUNTAIN VIEW
FACILITY NUMBER: 425850070

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.1(a)(2)
87468.1(a)(2) Personal Rights of Residents in All Facilities: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, Licensee failed to ensure all staff wore face coverings at all times while in the facilities. Staff 1 (S1) was not wearing a mask at the time of LPA’s arrival into the facility which poses an immediate health, safety and personal rights risk to residents in care.
POC Due Date: 11/25/2022
Plan of Correction
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Administrator shall notify all staff to wear masks at all times in the facility. Administrator agrees to conduct an infectious control training, review and train staff on all recent PIN’s released for 2022, including mask-wearing mandates, and provide copy of training and staff signatures to CCL by 11/25/2022. List of attendees with signatures to include first and last name of each attendee.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2022
LIC809 (FAS) - (06/04)
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