425850165-8-23-2021-29-AS-KKOS-C66TXA-20210823150648

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425850165
Report Date: 08/23/2021
Date Signed: 08/23/2021 03:07:42 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 VIA LOS PADRES		FACILITY NUMBER:	425850165
ADMINISTRATOR:	LOSITZKI, DOROTA		FACILITY TYPE:	740
ADDRESS:	908 VIA LOS PADRES		TELEPHONE:	(805) 705-9059
CITY:	SANTA BARBARA	STATE: CA	ZIP CODE:	93111
CAPACITY:	6	CENSUS: 6	DATE:	08/23/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Dorita Losikzki, Administrator		TIME COMPLETED:	03:00 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 announced pre-licensing visit to the facility. LPA met with Dorota Lositzki, Administrator and Anton Zamyatin, Co-Administrator. LPA arrived at 12:45 pm. Entrance Interview Conducted: This is a one-story home which will be licensed as a Residential Care Facility for the Elderly (RCFE). LPA toured facility with Administrators Lositzki and Zamyatin. There are currently 6 residents residing in the facility. Upon arrival, there were two caregivers and two administrators on duty. The facility has a fire clearance for one bedridden resident and six (6) non-ambulatory residents and consists of a living room, dining area, kitchen, and five bedrooms. Upon entrance of the residence, there is a walkway leading to the front door, garden areas, and a large covered patio that surrounds the facility. The facility has a locked garage used for storage including the facility’s commercial generator. There are no fountains or bodies of water. The entrance into the residence leads into the living and dining area. The kitchen consists of a refrigerator, microwave, sink, stove, oven, dishwasher, an air fryer, a panini grill, a hot water dispenser, and a crock pot. Trash and recycling bins are kept in a pullout drawer. All required CCL posters and signage are posted near the entrance and in the hallway. Personnel files, Residents’ files, and medications are kept in locked cabinets in the dining area. All files and medications are inaccessible to residents in care. Sharps are kept in a locked kitchen drawer and inaccessible to residents in care. Perishable foods for 2 days and non-perishable foods for 7 days are kept on hand for the residents. The living room and dining area are furnished with adequate furnishings to sustain a capacity of six residents. There is an additional common area at the end of the hallway providing access into Bedrooms 4 and 5. The additional living room has built-in cabinets. First aid kits and a locked first aid supply drawer are kept in the built-in cabinets. Please continue to 809-C, Pg 2.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2021

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 2

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 VIA LOS PADRES	FACILITY NUMBER: 425850165
	VISIT DATE: 08/23/2021

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
26
27
28
29
30
31
32

Bedrooms 1 and 2 share a bathroom off the hallway. Bedrooms 3 and 4 have private full bathrooms. Each bathroom has a sink, commode, and showers with grab bars. There is a half-bath off the hallway near the kitchen with a sink, commode and grab bars.
Bedrooms 2, 3, 4, and 5 have exit/entrance doors leading to the outdoor areas. Each exit/entrance door has a functioning door alarm.
Each resident’s bedroom has a bed, mattress, nightstand, chair, dresser, and closet. Overhead lighting and lamps on the nightstands provide sufficient lighting in each bedroom. Hallways have night lights and ample lighting.
The laundry area and storage area for cleaning agents and chemicals is located off the hallway.
The backyard consists of a covered, fenced, patio area with chairs and tables. The patio has built-in garden planters and walkways. The trash, recycling, and green waste cans are standardized cans located outside the facility. Each side of the residence has locked gates that are inaccessible to residents in care.
There is a hard-wired dual carbon monoxide detector and smoke alarm system in every room and every hallway.
There are three fire extinguishers that were serviced on 1/8/2021. The fire extinguishers are located near the common area close to the bedrooms, kitchen, and hallway.
LPA observed the facility’s comfortable room temperature upon arrival at 12:45 pm. Residents’ records, personnel documents and records of confidentiality are kept in a locked closet located in the kitchen area.
Residents will participate in various activities based on their individual interests and preferences, including reading, playing games (Dominoes, Bingo, and many others). Exercise classes on the premises are provided for the residents that include dancing, music, and singing. Outdoor activities, when permitted, include socializing, leisure walks, musical activities, dancing, visitors from community organizations, arts and crafts, games, and seasonal celebrations.

Per LPA's observation, physical plant is compliant to Title 22 Regulations at this time. Exit interview conducted. Copy of report issued.

LPA concluded the inspection. A copy of this report will be issued via email.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2021

LIC809 (FAS) - (06/04)

Page: 2 of 2