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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850165
Report Date: 07/30/2024
Date Signed: 07/31/2024 08:30:46 AM


Document Has Been Signed on 07/31/2024 08:30 AM - 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 PADRESFACILITY NUMBER:
425850165
ADMINISTRATOR:LOSITZKI, DOROTAFACILITY TYPE:
740
ADDRESS:908 VIA LOS PADRESTELEPHONE:
(805) 705-9059
CITY:SANTA BARBARASTATE: CAZIP CODE:
93111
CAPACITY:6CENSUS: 5DATE:
07/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:47 AM
MET WITH:Dorota Lositzki, AdministratorTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced required Annual Inspection at the above named 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.
At approximately 1:37 pm, the medication review revealed medications not given as prescribed as follows: Pantoprazole Sodium 40mg prescribed 1 tablet daily in the AM started on 7/12/2024 with a count of 90 had one (1) extra tablet; Carvedilol 3.125mg prescribed 1 tablet two times daily (1 tablet in AM, 1 tablet in PM) started on 7/2/2024 with a count of 180 had eight (8) extra tablets; and, Ferrous Sulfate prescribed 1 tablet daily in the AM started on 6/22/2024 with a count of 100 had eight (8) extra tablets.
Please continue to 809-C, Pg 2.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024
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 6


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: 07/30/2024
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 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.
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. At approximately 12:21 pm, LPA observed two patches of black mold in the shared bathroom off Bedroom 5. One patch measured 7”W x 4”H, located directly under the toilet paper dispenser. Another patch measured 4”W x 3”H located towards the back of the wall away from the toilet paper dispenser. LPA recommended the bathroom be inaccessible until the mold issue is resolved.
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 3/1/2024. 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.

Please continue to 809-C, Pg 3.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 07/31/2024 08:30 AM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
87465(c)(2) Incidental Medical and Dental Care: Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited when R1 did not receive their medication as prescribed, which posed an immediate health and safety risk to residents in care.
POC Due Date: 08/01/2024
Plan of Correction
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Administrator agrees to conduct medication training with all staff. Administrator agrees to provide proof of training including description, date training was completed, duration of training, and first and last name of trainer and trainees.
Type A
Section Cited
CCR
87303(a)
87303(a) Maintenance and Operation The facility shall be clean, safe, sanitary and in good repair at all times…

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited when black mold was distinctly visible on the bathroom wall of Bathroom 5 which poses an immediate health and safety risk to residents in care.
POC Due Date: 08/02/2024
Plan of Correction
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Administrator agrees to have mold issue addressed by a certified professional. Administrator agrees to keep residents out of the bathroom until the mold issue has been fully resolved.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024
LIC809 (FAS) - (06/04)
Page: 6 of 6


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: 07/30/2024
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 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.

The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in additional civil penalties.



Exit interview conducted. A copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024
LIC809 (FAS) - (06/04)
Page: 5 of 6