425850204-11-15-2021-29-AS-KKOS-C8SVDY-20211115152132

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425850204
Report Date: 11/15/2021
Date Signed: 11/15/2021 03:22:08 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:	MISSION VILLA		FACILITY NUMBER:	425850204
ADMINISTRATOR:	GERR, LISA		FACILITY TYPE:	740
ADDRESS:	321 W. MISSION STREET		TELEPHONE:	(805) 898-2709
CITY:	SANTA BARBARA	STATE: CA	ZIP CODE:	93101
CAPACITY:	14	CENSUS: 12	DATE:	11/15/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Lisa Gerr, Administrator		TIME COMPLETED:	02:45 PM

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Licensing Program Analyst (LPA) Kristin Kontilis conducted an announced pre-licensing visit to the facility. LPA met with Lisa Gerr, Administrator. LPA arrived at 12:25 pm.

Entrance interview conducted:

This is a one-story facility which will be licensed as a Residential Care Facility for the Elderly (RCFE). LPA toured the facility with Lisa Gerr, Administrator. The facility consists of a large common area used for dining and activities. Equipment and supplies are kept in a locked cabinet located in the hallway of the facility.
There are currently 12 residents residing in the facility. Upon arrival, there were three caregivers and one administrator on duty.
The kitchen, living room, and dining area are neat and clean. The kitchen consists of a refrigerator, freezer, stove/oven, microwave, coffee makers, toasters, fresh juice machine, mixer/blender, waffle iron, and two dishwashers. LPA observed a lockable gate denying access to the kitchen. Kitchen drawers including all sharps are kept in a locked drawer and are inaccessible to Residents in care.
Signs are posted on hallway bulletin boards stating COVID-19 symptoms should be reported to staff, Administrators, and LIcensee. All additional signage is properly posted.
There are twelve bedrooms and five bathrooms. Bedrooms 4, 9, and 10 are shared bedrooms. Bedrooms 1 and 2 are single private rooms with a shared private bath. Bedrooms 3, 9 and 10 are private bedrooms with a common bathroom. Bedrooms 5, 6, 7, 8, and 11 are private bedrooms with a shared bathroom off the hallway. Bedroom 12 is a private bedroom with a private bath. The bathrooms have secure grab bars and no skid flooring. The room temperature in the facility was measured at a comfortable temperature at 12:46 pm.
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. The hallway has night lights and ample lighting.
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: 11/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2021

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: MISSION VILLA	FACILITY NUMBER: 425850204
	VISIT DATE: 11/15/2021

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The facility has a fire clearance for 14 non-ambulatory residents and consists of a living room, dining area, and kitchen. A hospice waiver for 6 residents has been requested.
Upon entrance of the residence, there is a walkway leading to the front door. There are no fountains or bodies of water.
The patio 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 alarms in every bedroom, the hallway, and the kitchen.
There are four fire extinguishers that were serviced on 3/20/2021. The fire extinguishers are located near the common area close to the clean room entrance, med tech closet (hallway); two in the dining area, one near the bedrooms and one near the kitchen.
Residents will participate in various activities based on their individual interests and preferences, including reading, playing games, crafts, and singing activities. Exercise classes on the premises are provided for the residents that include chair yoga, dancing with exercise, music, and singing. Outdoor activities, weather permitting, include socializing, leisure walks, outside exercise, musical activities, and dancing. Visitors from community organizations will assist residents in BEI (Brain Experience Initiative) which includes trivia, math, and reading.

Per LPA's observation, physical plant is compliant to Title 22 Regulations at this time. Exit interview conducted. Copy of report 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: 11/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2021

LIC809 (FAS) - (06/04)

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