425850264-6-5-2024-29-AS-KKOS-D5XS8P-20240605133927

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425850264
Report Date: 06/05/2024
Date Signed: 06/05/2024 01:40:12 PM

Document Has Been Signed on 06/05/2024 01:40 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:	DIVINE CARE FOR THE ELDERLY		FACILITY NUMBER:	425850264
ADMINISTRATOR/ DIRECTOR:	JOSE, MARINO		FACILITY TYPE:	740
ADDRESS:	4866 FRANCES STREET		TELEPHONE:	(805) 967-5237
CITY:	SANTA BARBARA	STATE: CA	ZIP CODE:	93111
CAPACITY: 6		CENSUS: 6	DATE:	06/05/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:50 AM
MET WITH:	Marino "Mark" Jose, Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:00 PM

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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced Annual Required visit and inspection of the facility. Upon arrival, LPA was greeted by Administrator Marino “Mark” Jose. LPA explained the purpose of the visit. There were five (5) residents present and one (1) caregiver on duty.

Entrance interview conducted:

The facility is a one-story Residential Care Facility for the Elderly (RCFE). The facility accepts residents with a dementia diagnosis; has a waiver for four hospice residents; and a fire clearance for six non-ambulatory residents. Currently, there is one resident on hospice.
A tour of the physical environment was conducted. The front entry is a paved driveway leading to the front entrance with an outdoor sitting area conducive for outdoor visitation. The entry way leads into the living room, dining room, and kitchen. The backyard consists of a patio area, paved walkways, trees, planted garden areas and sitting areas conducive for outdoor visitations.
The kitchen is open style with a service counter for food preparation and cabinets surrounding the kitchen area. There is a refrigerator, a microwave, a toaster, a toaster oven, blender, an oven, and a stove. There is an ample amount of cabinets for food and appliance storage. Behind the dining area is an enclosed patio utilized as an office.
A locked medication cabinet is located in a cabinet in the dining area. It contains a first aid kit and medications for residents, residents’ records and personnel documents. The medications and documents are inaccessible to residents in care.
There are six bedrooms and three bathrooms available to residents. Bedrooms #1, 4, and 6 are private bedrooms with exits to the front yard or backyard. Bedroom #3 is a shared room with an exit to the backyard. Bedroom 3 has a private bathroom. Bedroom #2 is allocated for staff only with no access by residents. There are two bathrooms located off the hallways with access for all residents in care.
The laundry area is located in a locked closet located in the hallway near Bedrooms 5 and 6. Detergents and cleaning agents are kept in the laundry closet and are inaccessible to residents in care.

Please continue to 809-C, Pg 2.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2024

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: DIVINE CARE FOR THE ELDERLY	FACILITY NUMBER: 425850264
	VISIT DATE: 06/05/2024

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There is one fire extinguisher located at the front door of the facility. The fire extinguisher was serviced on 6/3/2024. There are nine (9) dual carbon monoxide/smoke alarms located throughout the facility. The carbon monoxide detector/smoke alarms are programmed to alert the local fire department when activated.
LPA observed the required posting of the complaint poster and Resident’s Rights. LPA inspected the facility for fire safety, personal accommodations, and food service.
The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, doors, floors and floor coverings are clean and in good repair.
Personnel records were reviewed for trainings, health screenings, and background clearances.
Residents’ records were reviewed for health screenings, medication administration, Physician’s orders, Appraisals, and Re-appraisals.
The facility is in compliance with Title 22 California Code of Regulations.

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

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2024

LIC809 (FAS) - (06/04)

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