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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425800662
Report Date: 05/15/2024
Date Signed: 05/16/2024 03:33:02 PM

Document Has Been Signed on 05/16/2024 03:33 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 BLANCAFACILITY NUMBER:
425800662
ADMINISTRATOR/
DIRECTOR:
INNA LYUTKO & NONNA ROZHKOFACILITY TYPE:
740
ADDRESS:6272 AVENIDA GANSOTELEPHONE:
(805) 683-2000
CITY:GOLETASTATE: CAZIP CODE:
93117
CAPACITY: 6CENSUS: 5DATE:
05/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:11 AM
MET WITH:Inna Lyutko, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:15 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 Staff 1 (S1) and stated the purpose of the visit. There were five (5) residents in care and one (1) staff on duty. Administrator Inna Lyutko arrived shortly thereafter.

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 three hospice residents; and a fire clearance for six non-ambulatory residents. Currently, there are two 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, doors, ceilings, floors and floor coverings were checked. Smoke alarms and carbon monoxide alarms are in good working order. The facility was seen to be in good repair inside and outside.
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 are readily available. 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, Pg 2.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE: DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 05/15/2024
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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. 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: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024
LIC809 (FAS) - (06/04)
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