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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801626
Report Date: 02/03/2022
Date Signed: 02/03/2022 02:14:03 PM

Document Has Been Signed on 02/03/2022 02:14 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 SAN MIGUELFACILITY NUMBER:
425801626
ADMINISTRATOR:ANTON ZAMYATINFACILITY TYPE:
740
ADDRESS:1403 SAN MIGUEL AVE.TELEPHONE:
(805) 963-1214
CITY:SANTA BARBARASTATE: CAZIP CODE:
93109
CAPACITY: 6CENSUS: 6DATE:
02/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Katarina Zamyatina; Anton ZamyatinaTIME COMPLETED:
02:20 PM
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On 02/03/22 at 12:25 p.m., Licensing Program Analyst (LPA) Toan Luong conducted an unannounced One Year Annual - Infection Control Visit. LPA met with Administrators Katerina Zamyatina and Anton Zamyatina and explained the purpose of the visit.

At 12:25 p.m, LPA observed visitation sign and facility policy at the entrance. Facility staff conducted temperature check, symptom screening, and recorded contact information of LPA. A binder with California Department of Social Services Provider Information Notices were on a table at the entrance along with gloves, hand sanitizer, and visitor's log. LPA toured the Residential Facility for the Elderly and observe signs promoting physical distance and Covid-19 practices throughout the facility. Bathrooms had hand washing signs, paper towels, and soap. All staff were observed wearing masks. Facility maintained a 30 day supply of personal protective equipment.
At 1:20 p.m. LPA completed items in the Infection Control Module with administrators. Administrators answered yes to all questions posed in the Infection Control Module. Module was addressed with administrators to satisfaction.

No deficiency was issued. LPA conducted exit interview with administrators and emailed report.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE: DATE: 02/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2022
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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