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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850210
Report Date: 10/20/2023
Date Signed: 10/20/2023 03:46:37 PM


Document Has Been Signed on 10/20/2023 03:46 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 CAMBRIA WAYFACILITY NUMBER:
425850210
ADMINISTRATOR:ASEL TELMANFACILITY TYPE:
740
ADDRESS:803 CAMBRIA WAYTELEPHONE:
(818) 983-1002
CITY:SANTA BARBARASTATE: CAZIP CODE:
93105
CAPACITY:6CENSUS: 5DATE:
10/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Asel Telman, AdministratorTIME COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced required Annual Inspection at the facility. LPA met with Asel Dzheentaeva.

Entrance Interview Conducted:
The facility is a one-story Residential Care Facility for the Elderly (RCFE). The facility has been approved for six non-ambulatory residents of which two may be bedridden and maintains a hospice waiver for six residents.
There are currently 6 residents residing in the facility. Upon arrival, there were five residents in care with two caregivers and one administrator on duty. Four residents are currently on hospice.
The facility consists of a living room, dining area, kitchen, and five bedrooms. Upon entrance, there is a walkway leading to the front door and garden areas. The front porch 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.
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. 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: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2023
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 CAMBRIA WAY
FACILITY NUMBER: 425850210
VISIT DATE: 10/20/2023
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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 been designated as bedridden bedrooms. Each bedridden bedroom has an exit/entrance door 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, closet, and a motion detector for movement. 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 in the locked garage.
The backyard consists of an umbrella, 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.
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 2/22/2023.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 participate at will in various activities based on their individual interests and preferences, including bird watching, musical activities, games (Dominoes, Bingo, and many others). Exercise classes on the premises are provided for the residents that include physical therapy, music, and singing. Outdoor activities, when permitted, include bird watching, socializing, leisure drives and walks, and outside exercise. Volunteers from community organizations will assist residents in reading, arts and crafts activities, games, and seasonal celebrations.
Administrator’s certificate is current. All staff have received a criminal background clearance and are associated to the facility.

Exit interview conducted. No deficiencies noted; no citations issued. Report issued at the time of the visit.

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

DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
LIC809 (FAS) - (06/04)
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