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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801626
Report Date: 12/14/2022
Date Signed: 12/14/2022 06:04:25 PM

Document Has Been Signed on 12/14/2022 06:04 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:
12/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:58 AM
MET WITH:Ekaterina Zamyatina and Anton Zamyatin, Co-AdministratorsTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced Annual Infection Control Inspection visit at the above-named facility. LPA arrived at 11:58 pm and was greeted by Nurkyz Jumataeva, Caregiver and explained the purpose of the visit. At the time of arrival, there were two (2) staff on duty and six (6) residents in care. Ekaterina Zamyatina arrived at approximately 12:10 pm and Anton Zamyatin arrived at approximately 12:18 pm..
Entrance interview conducted.
The facility is a one-story Residential Care Facility for the Elderly (RCFE). Currently, there are three residents on hospice and one bedridden resident.
A tour of the physical environment and accommodations were assessed, and the following was noted: LPA observed the required posting of the complaint poster, bill of rights and Resident’s Rights. LPA inspected the one-story 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 were checked. The facility was seen to be in good repair inside and outside. There are four fire extinguishers, inspection was current as of 2/1/2022. The carbon monoxide alarm and smoke alarms are hard wired and in good working order. Additionally, the facility has two pull fire alarms.
The kitchen area was sufficiently stocked with two-day perishables and seven days of non-perishables. Snacks and beverages are readily available for Residents. Frozen foods are properly wrapped and stored appropriately. LPA observed the kitchen cabinets, refrigerator, stove, and counters are clean.
Medications, First Aid kit, and additional first aid supplies are kept in a locked centrally stored cabinet. First aid kit was observed to be complete.
Residents participate independently in music entertainment, joyous movement (music and chair exercise), floral arranging, books by Braille, pet therapy including miniature pony therapy, arts and crafts, gardening and outings to parks, restaurants, and other local attractions.

Please continue to 809-C.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE: DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/14/2022
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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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: CASA SAN MIGUEL
FACILITY NUMBER: 425801626
VISIT DATE: 12/14/2022
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 The front yard consists of walkways, sitting areas, and garden areas. The backyard has walkways, garden sitting areas, and a gazebo. There are no bodies of water. The recycling bin, green waste bin, and trash bins are standard bins with flip lids. A locked garage is located at the front of the home used for storing supplies.
The kitchen, living room, and dining area are neat and clean. The facility maintains a comfortable temperature.
There are six private bedrooms. Bedrooms #1, 2, 3, and 4 have private-half bathrooms. Each bedroom has a bed, nightstands, and lights and nightstand lamps to provide sufficient lighting.
There are two half baths with hallway access available to all residents. There is one full-size bathroom/shower room utilized for all residents. The bathrooms have secure grab bars and no skid flooring.
All persons associated with the facility have criminal record clearance. Administrator certificate is valid.
If any suspected or confirmed cases of COVID-19 are found in the facility a staff will be assigned to only work with those quarantined/isolated individuals and will not work with other COVID negative individuals until cleared by Health Department. Staff will use full PPE with N95 masks and face shields when dealing with any pending or confirmed cases of COVID-19. Precautionary Droplet signs will be posted on any room with quarantine or isolated individuals.
PPE supplies will be located immediately outside those rooms when required. Facility has a 30-day supply of PPE on hand. Facility has plans for delivering medications and meals to any quarantined/isolation resident room.
The facility has proper cleaning and disinfectant sprays. Facility Administrator has a plan in place for when and whom to notify in an outbreak or other emergencies. Administrator will keep a line list of all vaccinated and tested staff/residents in care with dates/results.
Facility has conducted training on infection prevention, symptoms, transmission and PPE use. Facility has non-punitive sick leave polices for staff. Staff who have a respiratory illness are requested to stay home and not report to work.
Activities have been modified to individuals or small groups with social distancing. Residents' medication is delivered in 30-day supplies to the facility. The facility ensures proper cleaning is done on frequently touched surfaces and between any individuals sharing of space or items.
Sinks were well stocked with soap, paper towels and hand washing signs. Staff and resident records are kept in the locked staff office. Facility observes guidance changes and the most up-to-date guidance from CCL-PINS, CDC, CDPH, and local health departments should be followed to remain in compliance. The most stringent orders should be followed by any of these agencies.
Exit interview conducted. No citations issued. A copy of this report has been issued via email.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022
LIC809 (FAS) - (06/04)
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