425850165-8-22-2023-29-AS-KKOS-CUXU2V-20230822151233

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425850165
Report Date: 08/22/2023
Date Signed: 08/22/2023 03:12:51 PM

Document Has Been Signed on 08/22/2023 03:12 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 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: 5	DATE:	08/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:10 AM
MET WITH:	Dorota Lositzki, Administrator		TIME COMPLETED:	03:45 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 required Annual Inspection at the facility. LPA met with Dorota Lositzki, Administrator. Entrance Interview Conducted: This is a one-story home licensed as a Residential Care Facility for the Elderly (RCFE) with a dementia diagnosis. The facility has been approved for a hospice waiver for 6 residents and has a fire clearance for 6 non-ambulatory residents, one of which can be bedridden. LPA explained the reason for the visit and toured facility with Administrator Lositzki. Upon arrival, there were 5 residents in care with two caregivers and one administrator on duty. Upon entrance into the residence, there is a walkway leading to the front door, garden areas, and a covered patio that surrounds the facility. The facility has a garage used for storage. There are no fountains or bodies of water. The facility consists of a living room, dining area, kitchen, and five bedrooms. 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 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: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

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 VIA LOS PADRES	FACILITY NUMBER: 425850165
	VISIT DATE: 08/22/2023

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Bedrooms 1 and 2 are private rooms and share a bathroom off the hallway. Bedrooms 3 and 4 are private bedrooms with a private bathroom. Bedroom 5 is a shared bedroom with a private bathroom for the occupants in Bedroom 5 only. 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. All grab bars are securely installed.
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 located throughout the facility.
There are three fire extinguishers that were serviced on 2/7/2023. The fire extinguishers are located near the common area close to the bedrooms, kitchen, laundry room, and hallway.
LPA observed the facility’s comfortable room temperature.
Residents will participate at will 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 offered for the residents that include dancing, music, and singing. Outdoor activities, when permitted, include socializing, leisure walks, musical activities, dancing, visitors from community organizations, games, and seasonal celebrations.

Per LPA's observation, physical plant is compliant to Title 22 Regulations. Exit interview conducted. No citations issued at this time. Copy of report issued at the time of the visit.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

LIC809 (FAS) - (06/04)

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