425850088-12-22-2020-29-AS-DCHZ-BWK5M7-20201222190416

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425850088
Report Date: 12/22/2020
Date Signed: 12/22/2020 07:05:11 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 SANTECITO		FACILITY NUMBER:	425850088
ADMINISTRATOR:	ZAMYATINA, EKATERINA		FACILITY TYPE:	740
ADDRESS:	717 SANTECITO DR.		TELEPHONE:	(805) 455-9953
CITY:	SANTA BARBARA	STATE: CA	ZIP CODE:	93108
CAPACITY:	6	CENSUS: 0	DATE:	12/22/2020
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Katerina Zamyatina, Administrator, and Antone Zamyatina		TIME COMPLETED:	02:39 PM

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At 1:10 pm, Licensing Program Analyst (LPA) Chavez conducted a pre-licensing televisit to the facility above. LPA met with Katerina Zamyatina, Administrator and Antone Zamyatina, and explained the purpose of the visit. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted via FaceTime with Katerina Zamyatina and Antone Zamyatina.

Administrator took LPA on a physical plant tour of the facility.

Building and Grounds: There is a locked closet next to the kitchen for centrally stored medications and resident files. In the hall next to the dining room, staff files are kept in a cabinet not secure from staff. Administrator will move files to a locked cabinet within the locked closet next to kitchen. Administrator will take a video of staff files being locked in cabinet and send to LPA. Cleaning supplies are kept in a locked closet in entryway. Walls, ceilings, floors, window screens and areas around the facility are clean, painted and/or in good repair. Knives are in a unlocked kitchen drawer.

Fire extinguishers (two) were inspected on December 21, 2020. Smoke detectors and carbon monoxide detectors were tested and operating properly. Doors and passageways are unobstructed. The facility does not keep firearms or ammunition on the premises. Bathrooms are kept clean and in good repair. Grab bars and non-slip mats are present in both bathrooms and in good working order. Water temperature in Bathroom #1 (master bath) is 110 F, Bathroom #2 is 117 F, Bathroom #3 is 110 F, Bathroom #4 is 110 F, Bathroom #5 is 110 F, and Bathroom #6 is 110 F.

Continued on 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2020

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 SANTECITO	FACILITY NUMBER: 425850088
	VISIT DATE: 12/22/2020

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Laundry room with cleaning supplies is in a locked room accessible from backyard patio. All windows have screens in good repair. The facility has two sheds for storage in the backyard containing gardening items. Patio furniture is in good working order. Outdoor activity space has a gazebo for shade and furnished for outdoor use. The facility maintains a comfortable indoor temperature of 68 F.

Furniture and Equipment: An emergency exiting plan is posted at entrances and exits and emergency phone numbers are posted in the hallway. A current disaster and mass casualty plan are maintained at the facility. The CCLD reporting poster “See Something, Say Something” is posted, however, the size is not in compliance. Admin will obtain a 20”x26” color poster, display in facility prominently, and take a photo or provide copy of receipt where poster was made. The facility has a telephone on the premises, available to clients. LPA had administrator test the phone which is in good working order. Facility phone number is 805-770-5033 and fax # 888-370-5244.

The facility has a 2007 Chrysler van to transport residents.

First-aid kit, manual and supplies are maintained. Refrigerator is maintained at 40 degrees Fahrenheit and the freezer was recorded at 5 degrees Fahrenheit. Freezer temperature is not in compliance and should be maintained at 0 F. Administrator will adjust freezer temperature and send a video of freezer temperature being recorded and send to LPA. Food storage and preparation areas are clean and appropriate for food preparation. All appliances are clean and operating properly. Food utensils, dishes, glasses are clean and in good repair. Hot water temperature was measured in the kitchen sink at 112 F.

All rooms are appropriately furnished for their intended use. The facility has a covered fireplace. Each client has an adult bed with mattress, pad, bedsprings, and pillow which are clean and in good repair. Each bed is fitted with sheets, pillowcase, blankets and bedspreads that are clean and in good repair. Each client has adequate dresser and closet space for clothing and belongings.

Items in underlined are to be completed by the Administrator by December 28, 2020.

At 2:39 pm, a telephonic exit interview was conducted with Katerina Zamyatina and Antone Zamyatina, and an electronic copy of the report was emailed for signature to be returned to LPA by email.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2020

LIC809 (FAS) - (06/04)

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