<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850087
Report Date: 02/04/2021
Date Signed: 02/04/2021 02:51:50 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 CAMBRIA SBFACILITY NUMBER:
425850087
ADMINISTRATOR:ANDREICHENKO, VIKTORIIAFACILITY TYPE:
740
ADDRESS:803 CAMBRIA WAYTELEPHONE:
(805) 403-7455
CITY:SANTA BARBARASTATE: CAZIP CODE:
93105
CAPACITY:6CENSUS: 6DATE:
02/04/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Viktoriia AndreichenkoTIME COMPLETED:
12:26 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) JoAnn Rosales conducted a Pre-licensing tele-visit with Licensee/Representative/Administrator Viktoriia Andreichenko due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures. This application is a change of ownership from Casa Cambria #425801988. Component III was conducted in conjunction with this pre-licensing visit.

LPA inspected facility for Fire Safety, Personal Accommodations and Services, Medication Procedures, and Food Service. First-aid kit is complete, facility has adequate linen, water and nonperishable food supplies.

Facility has 4 private bedrooms, 1 shared bedroom, 1 employee room and 4 bathrooms. Hot water temperature tested at 114.6 degrees Fahrenheit in resident bathroom. The common areas were appropriately furnished and lighting was adequate. There are games, books and magazines for activities. Resident medications and records are kept in a lock filing cabinet in the kitchen. Staff records are kept in a locked cabinet in the kitchen. Disinfectants, cleaning solutions and poisons are kept inaccessible. LPA observed smoke detectors and carbon monoxide detectors operating properly and fire extinguishers properly charged. Fire clearance is approved for 6 non-ambulatory residents of which 1 may be bedridden in bedroom #5.

The physical plant is in compliance with Title 22 regulations at this time.

A telephonic exit interview was conducted with Licensee/Representative/Administrator and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2021
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 1