425800662-5-26-2023-29-AS-KKOS-CS7S66-20230526133525

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425800662
Report Date: 05/26/2023
Date Signed: 05/26/2023 01:35:50 PM

Document Has Been Signed on 05/26/2023 01:35 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:	VILLA BLANCA		FACILITY NUMBER:	425800662
ADMINISTRATOR:	INNA LYUTKO & NONNA ROZHKO		FACILITY TYPE:	740
ADDRESS:	6272 AVENIDA GANSO		TELEPHONE:	(805) 683-2000
CITY:	GOLETA	STATE: CA	ZIP CODE:	93117
CAPACITY: 6		CENSUS: 6	DATE:	05/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Nonna Rozhko, Administrator		TIME COMPLETED:	01:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced Annual Required visit and inspection of the facility. LPA arrived at 11 am and was greeted by Administrator Nonna Rozhko, and six (6) residents present. Administrator Inna Lyutko arrived at approximately 11:25 AM. LPA informed Administrator the purpose of the visit. 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 two hospice residents; and a fire clearance for six non-ambulatory residents. Currently, there are no residents on hospice residing in the facility. A tour of the physical environment and accommodations were assessed. The following was noted: LPA observed the required posting of the complaint poster, Resident’s Rights. LPA inspected the facility for fire safety, personal accommodations, and food service. First aid kit was observed to be complete. The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked. The facility was seen to be in good repair inside and outside. The most recent fire inspection was conducted on 5/23/2023. Smoke alarms and carbon monoxide alarms are in good working order. The kitchen area was sufficiently stocked with two-day perishable and seven-day non-perishables. Snacks and beverages are available for Residents in the facility upon request. LPA observed the kitchen cabinets, refrigerator, stove, and counters are clean. LPA observed the sharps are kept in a locked drawer near the stove. The kitchen trash is a covered container located in the kitchen area. Cleaning agents are kept in a locked cabinet under the kitchen sink. Medications are also kept in a locked cabinet located in the kitchen Please continue to 809-C.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023

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: VILLA BLANCA	FACILITY NUMBER: 425800662
	VISIT DATE: 05/26/2023

NARRATIVE

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The front yard has paved walkways and tiled walkways and plants. The backyard has a patio with outdoor furniture and an umbrella for shade. The recycling bin, green waste bin, and trash bins are standard bins with flip lids. A locked private staff room is located in the facility near the residents' rooms. The laundry area is part of the locked staff room.
The living room and dining area are neat and clean. The facility maintains a comfortable temperature at 72 degrees Fahrenheit (F). Hallways, bedroom doors, and walls are in good repair.
The facility has six (6) bedrooms for six residents. Each resident’s room has lights and nightstand lamps to provide sufficient lighting. Bedrooms 1, 4, and 5 are private bedrooms with a private bathroom. Bathroom #1 is a shared bathroom with hallway access. The bathrooms have grab bars with easy access into the shower area.
Residents participate at will in activities such as but not limited to listening to a pianist, reading materials, coloring, word puzzles, picture puzzles, games, walks around the neighborhood, outings to local eateries, local attractions, concerts, and religious celebrations. The facility also has parties for residents to celebrate birthdays and holidays.
All medications have signed and dated written orders from a physician. Residents’ files were reviewed. LPA noted that on file for each resident was the following: Physician’s Reports, Admission Agreements, Medical Assessments, Identification and Emergency information, Appraisals/Needs Service Plan, and Medical Accounting Records (MARs).
All staff have been properly associated to the facility.
Staff files were reviewed. Administrator/Licensees' certifications are current.

Exit interview conducted. No citations were issued. Copy of report issued at the time of the visit.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023

LIC809 (FAS) - (06/04)

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