425801158-10-30-2024-29-AS-KKOS-DAJQT2-20241030122624

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425801158
Report Date: 10/30/2024
Date Signed: 10/30/2024 12:26:31 PM

Document Has Been Signed on 10/30/2024 12:26 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:	MESA CARE		FACILITY NUMBER:	425801158
ADMINISTRATOR/ DIRECTOR:	VALENTYNA POLUNETS		FACILITY TYPE:	740
ADDRESS:	2424 CALLE SORIA		TELEPHONE:	(805) 965-2428
CITY:	SANTA BARBARA	STATE: CA	ZIP CODE:	93109
CAPACITY: 6		CENSUS: 6	DATE:	10/30/2024
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:08 AM
MET WITH:	Valentyna Polunets, Administrator		TIME VISIT/ INSPECTION COMPLETED:	01:30 PM

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Licensing Program Analysts (LPAs) Brian Phillips and Kristin Kontilis conducted an unannounced continuance Inspection of the above-named facility. LPAs were greeted by Co-Administrator Alex Polunets.. Administrator Valentina Polunets arrived at approximately 10:30 am. LPAs explained the purpose of the visit

At the time of arrival, Co-Administrator was on duty with six residents in care. The facility is a Residential Care Facility for the Elderly (RCFE) The facility accepts residents with a dementia diagnosis; has a hospice care waiver for four residents; and a fire clearance for six non-ambulatory residents, of which two (2) can be bedridden. Currently there are three (3) residents on hospice residing in the facility.

Entrance interview conducted.

The facility is a one-story facility located in a residential area. LPA observed the required posting of the complaint poster and Resident’s Rights. The one-story facility was inspected 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 were checked. The facility was seen to be in good repair inside and outside. LPA observed the fire inspection was last conducted on 8/28/2024. LPA observed eight smoke alarms and 1 carbon monoxide detector were in good working order.
Entrance into the facility leads into the common area and the dining area.
The kitchen cabinets, refrigerator, stove, and counters are clean. The facility is sufficiently stocked with at least two days of perishables and seven days of non-perishables. Snacks and beverages are available for residents in care upon request. Sharps are kept in the laundry room.
There are six private bedrooms and one extra bedroom. Bedrooms #5 and #7 have a private bathroom. There are two bathrooms off the facility hallway available to all residents in care.

Please continue to 809-C, Pg 2..

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

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: MESA CARE	FACILITY NUMBER: 425801158
	VISIT DATE: 10/30/2024

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Residents' records were reviewed. Admission Agreements, Health Screenings, Needs and Services Plans, Appraisals, Pre-Appraisals, Consent Forms, Physician's Reports have been signed and all records are current.
Staff records reviewed revealed trainings are up-to-date, personnel records are current and up-to-date.

Exit interview conducted. Technical assistance noted. Copy of report issued at the time of the visit.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

LIC809 (FAS) - (06/04)

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