425850088-1-27-2022-29-AS-KKOS-CB3W32-20220127155513

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425850088
Report Date: 01/27/2022
Date Signed: 01/27/2022 03:56:16 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:	ANTON ZAMYATIN		FACILITY TYPE:	740
ADDRESS:	717 SANTECITO DR.		TELEPHONE:	(805) 455-9953
CITY:	SANTA BARBARA	STATE: CA	ZIP CODE:	93108
CAPACITY:	6	CENSUS: 6	DATE:	01/27/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:05 PM
MET WITH:	Katerina Zamyatina, Administrator		TIME COMPLETED:	03:40 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) Kristin Kontilis conducted an unannounced Annual Required visit and Infection Control Inspection of the facility. LPA arrived at 1:05 PM and was greeted by Celibi Salgado, Caregiver and explained the purpose of the visit. At the time of arrival, there were three (3) staff on duty and six (6) residents present. Ekaterina Zamyatina was present at the time of LPA’s arrival. Anton Zamyatin arrived at approximately 1:40 PM. Entrance interview conducted. There are currently six (6) residents residing in the facility. The facility is a one-story Residential Care Facility for the Elderly (RCFE). Currently, there are two residents on hospice. 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 physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked. The facility was seen to be in good repair inside and outside. Fire inspection was current. There are eight (8) dual carbon monoxide/smoke alarms are hard wired and will immediately notify the local fire department. The kitchen area was sufficiently stocked with two-day perishables and seven days of non-perishables. Snacks and beverages are readily available for Residents. Frozen foods are properly wrapped and stored appropriately. LPA observed the kitchen cabinets, refrigerator, stove, and counters are clean. The kitchen has an oven, stove, refrigerator, microwave, bread maker, blender, steamer, and toaster. The residents’ eating utensils are specifically marked for each resident as a COVID-19 best safety practice. Medications, First Aid kit, and additional first aid supplies are kept in a locked centrally stored cabinet located in the dining area. Residents’ medication dishes are specifically marked for each resident as a COVID-19 best safety practice. Please continue to 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022

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 SANTECITO	FACILITY NUMBER: 425850088
	VISIT DATE: 01/27/2022

NARRATIVE

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The recycling bin, green waste bin, and trash bins are standard bins with flip lids. There is a locked storage shed with gardening tools and equipment. The contents of the storage shed are inaccessible to residents in care.
The kitchen, living room, and dining area are neat and clean. The facility maintains a comfortable temperature at 69.8 degrees Fahrenheit (F). Hallways, bedroom doors, and walls are in good repair.
There are six private bedrooms. Bedrooms #1, 4, 5, 6 and 7 have private-half bathrooms. Bedroom #3 has a bathroom across the hallway. Bedroom #2 is an employee room and remains locked at all times with no access by residents in care. Each bedroom has a bed, nightstand, and a lamp to provide sufficient lighting. There is one full-size bathroom/shower room utilized for all residents. The bathrooms have secure grab bars and no skid flooring.
Residents’ files and personnel files are kept in a locked cabinet in the dining area.
All persons associated with the facility have criminal record clearance.

Exit interview conducted. No citations issued. A copy of this report has been issued.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022

LIC809 (FAS) - (06/04)

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