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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850165
Report Date: 09/16/2025
Date Signed: 09/16/2025 03:50:16 PM

Document Has Been Signed on 09/16/2025 03:50 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 PADRESFACILITY NUMBER:
425850165
ADMINISTRATOR/
DIRECTOR:		LOSITZKI, DOROTAFACILITY TYPE:
740
ADDRESS:908 VIA LOS PADRESTELEPHONE:
(805) 705-9059
CITY:SANTA BARBARASTATE: CAZIP CODE:
93111
CAPACITY: 6CENSUS: 3DATE:
09/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:50 AM
MET WITH:Dorota Lositzki, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:30 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 purpose of the visit and toured facility with Administrator Lositzki.
Upon arrival, there were 3 residents in care with one caregiver and one administrator on duty. There are three (3) residents currently on hospice.
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. 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 11:55 am, LPA observed a medication bubble pack of Furosemide 20mg tablets and a medication cup with 3 medications on the kitchen counter. At the time of the observation, there were two residents sitting at the dining table approximately 6 feet from the medication bubble pack and the medication cup. No staff were in the dining area at the time of observation. Please continue to 809-C, Pg 2.
NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Kristin Kontilis
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 09/16/2025
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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. Bedroom 3 has been converted into a staff room. Bedroom 4 is a private bedroom 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 a 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 3/8/2025. 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.

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.

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Kristin Kontilis
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/16/2025 03:50 PM - It Cannot Be Edited


Created By: Kristin Kontilis On 09/16/2025 at 02:21 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CASA VIA LOS PADRES
FACILITY NUMBER: 425850165

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
87465(h)(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interviews, the licensee did not comply with the section cited above when a bubble pack of Furosemide 20mg and a medication cup with 3 medications were observed on the kitchen counter with two residents and no staff present in the dining area which poses an immediate health and safety risk to residents in care.
POC Due Date: 09/18/2025
Plan of Correction
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Licensee/Administrator agrees to submit a written statement acknowledging 87465 in its entirety and will submit a written statement stating medications will be kept in a locked cabinet inaccessible to residents in care at all times.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kelly Burley
NAME OF LICENSING PROGRAM MANAGER:
Kristin Kontilis
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2025


LIC809 (FAS) - (06/04)
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