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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850070
Report Date: 07/21/2023
Date Signed: 07/21/2023 05:54:28 PM


Document Has Been Signed on 07/21/2023 05:54 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 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: 2DATE:
07/21/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:09 AM
MET WITH:Viktoriia Andreichenko, AdministratorTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kristin Kontilis conducted a Case Management visit to address deficiencies noted during Complaint Control #29-AS-20230717161806 investigation visit conducted on 7/21/2023. LPA met with Administrator Viktoriia Andreichenko and explained the purpose of the visit.

During today’s visit, LPA obtained a copy of death certificates for two residents who passed away in March 2023 and June 2023. LPA reviewed facility files for notification from the facility of the residents’ passing. As of today’s visit, no death reports have been received by CCL since the facility license was issued on or about 11/25/2020. LPA requested copies of death reports and a list of all deaths for residents who have passed away while they were residents at the facility.

LPA reviewed facility files for notification from the facility of serious illness/serious injury reports. As of today’s visit, LPA reviewed various residents’ documents including but not limited to “After Visit Summary” reports for residents who had been administered medical attention. Administrator stated Serious Illness/Serious Injury reports have not been submitted to CCL for hospital visits, visits to Urgent Care, and other serious illness/serious injury occurrences.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to 809-D).



Exit interview conducted, deficiencies cited, and the report and appeal rights issued during today’s visit
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2023
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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Document Has Been Signed on 07/21/2023 05:54 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 MOUNTAIN VIEW
FACILITY NUMBER: 425850070

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/22/2023
Section Cited
CCR
87211(a)

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87211(a) Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: ...

This requirement is not met as evidenced by:
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Administrator agrees to provide CCL with Serious Illness/Serious Injury Reports for any and all residents who passed away and/or who sustained a serious injury and/or illness since 11/25/2020.
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Based on record review and interviews, the Licensee did not comply with the section cited above as Serious Illness/Serious Injury and Death Reports were not submitted to CCLD as required which poses an immediate health and safety risk to residents in care.
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Administrator agrees to review and submit a signed acknowledgement of understanding for CCR 87211 in its entirety.

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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: 07/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2023
LIC809 (FAS) - (06/04)
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