425850088-1-18-2023-29-AS-JOLN-CN7U26-20230118141126

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425850088
Report Date: 01/18/2023
Date Signed: 01/18/2023 02:12:08 PM

Document Has Been Signed on 01/18/2023 02:12 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 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:	01/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Anton Zamyatin, Administrator and Ekatrina Zamyatina, Licensee		TIME COMPLETED:	01:50 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) Olson conducted an on-site 1 year infection control annual visit to the facility above on 1/18/2023 around 12:30 PM. LPA met with Anton Zamyatin, Administrator and Ekatrina Zamyatina, Licensee and explained the purpose of the visit. LPA took a physical plant tour of the facility with Administrator and Licensee. The facility has submitted an Infection Control Plan to the department. The facility has an entry point at the front door where everyone entering completes temperature screening on all staff and visitors wanting to come into the facility. The entry station has hand sanitizer along with a thermometer. The staff screen residents for symptoms and temperature once a day. Increased monitoring is conducted if any change of condition are noted or any residents are showing any signs, symptoms or a temperature. Signs are posted in the front door and entry area regarding Covid-19. Staff makes sure residents have a mask when leaving the facility on outings into the community. All staff will wear face coverings in the facility and when on outings with residents. Facility has areas for visiting inside and outside. The facility also offers virtual and telephone communications to all residents in care. Staff, Residents and visitors are informed of the facilities infection control policies. New residents and staff will be tested and negative results received before working or residing in the facility. The facility has procedures and plans for screening, isolation, testing, when to call 911 and notifying all responsible parties and agencies when needed. Administrator is in charge of infection control and provides training and education to staff, residents and visitors. Staff will use full PPE with N95 masks and face shields when working with any pending or confirmed cases of Covid-19. Facility is able to dedicate a single room for residents so isolation can be arranged when and if needed. The facility has single and double rooms that are disinfected and wiped down daily. Precautionary Droplet signs will be posted on any room with quarantine or isolated individuals. PPE supplies will be located right outside those rooms when required. Facility has a 30 day supply of PPE on hand. Continued on 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023

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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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: 01/18/2023

NARRATIVE

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Facility has plans for delivering medications and meals to any quarantined/isolation resident rooms. 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 on infection prevention, symptoms, transmission and PPE use. Facility has non-punitive sick leave polices for staff. Sick staff are requested to stay home and not report to work if ill. 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, and paper towels. Staff and resident records are kept in a locked cabinet. Facility does realize 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. Administrator Certificate is valid. Fire extinguisher was charged and inspected annually. The facility has working smoke and carbon monoxide detectors throughout the facility.

At approximately 1:30 pm, LPA reviewed Guardian/ Department of Social Services, Community Care Licensing Division, Licensing Information System (LIS), Facility Personnel and facility staff roster and determined that all staff are fingerprint cleared and associated to the facility.

No deficiencies observed during the visit and all infection control protocols are implemented and are being followed.

Exit interview completed and a copy of report was emailed to Administrator/ Licensee.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023

LIC809 (FAS) - (06/04)

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