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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850210
Report Date: 10/11/2021
Date Signed: 10/11/2021 03:34:33 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 CAMBRIA WAYFACILITY NUMBER:
425850210
ADMINISTRATOR:DZHEENTAEVA, ASELFACILITY TYPE:
740
ADDRESS:803 CAMBRIA WAYTELEPHONE:
(818) 983-1002
CITY:SANTA BARBARASTATE: CAZIP CODE:
93105
CAPACITY:6CENSUS: 6DATE:
10/11/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Asel Dzheentaeva and Anton Zamyatin, Co-AdministratorsTIME 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 Asel Dzheentaeva and Anton Zamyatin, Co-Administrators. LPA arrived at 1:35 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 Co-Administrators.
There are currently 6 residents residing in the facility. Three residents are on hospice. Upon arrival, there were two caregivers and three administrators on duty.
The facility has a fire clearance for 2 bedridden residents and four (4) non-ambulatory residents and consists of a living room, dining area, kitchen, and five bedrooms. A hospice waiver for 5 residents has been requested.
 Upon entrance of the residence, there is a walkway leading to the front door and garden areas. The front part of the house has a covered patio with available seating. 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 common living area from a hallway. The kitchen consists of a refrigerator, microwave, sink, stove, oven, dishwasher, and a toaster. 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 kitchen 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. First aid kits and a locked first aid supply cabinet are kept in the built-in locked cabinets located in the hallway.
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: 10/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2021
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: CASA CAMBRIA WAY
FACILITY NUMBER: 425850210
VISIT DATE: 10/11/2021
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Bedroom 1 is a shared bedroom with a shared private bath. Bedrooms 2 and 3 are private bedrooms with private bathrooms. Bedrooms 4 and 5 are private bedrooms and share a bathroom off the hallway. Each bathroom has a sink, commode, and showers with grab bars.
Bedrooms 1 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, night stand, chair, dresser, and closet. Overhead lighting and lamps on the night stands 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 second 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 2/3/2021.The fire extinguishers are located near the common area close to the bedrooms, kitchen, hallway, and in the garage.
LPA observed the facility’s comfortable room temperature 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 “Gentle Movement” (dancing with exercise), music, and singing. Outdoor activities, when permitted, include socializing, leisure walks, outside exercise, musical activities, and dancing. Visitors from community organizations will assist residents in arts and crafts activities, 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 via email.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2021
LIC809 (FAS) - (06/04)
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