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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850018
Report Date: 06/09/2021
Date Signed: 06/09/2021 04:41:48 PM

Document Has Been Signed on 06/09/2021 04:41 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 SALISBURYFACILITY NUMBER:
425850018
ADMINISTRATOR:ZAMYATINA, EKATERINAFACILITY TYPE:
740
ADDRESS:264 SALISBURY AVETELEPHONE:
(805) 455-9953
CITY:GOLETASTATE: CAZIP CODE:
93117
CAPACITY: 6CENSUS: 6DATE:
06/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Administrator Ekaterina Zamyatina; Adminitrator Anton ZamyatinaTIME COMPLETED:
04:45 PM
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On 6/9/21, at 2:40 PM, Licensing Program Analyst (LPA) Toan Luong initiated facility risk assessment questionnaire. LPA conducted an unannounced onsite one year infectious control annual visit to the facility. LPA met with Administrators Ekaterina Zamyatina and Anton Zamyatina and explained the purpose of the visit.

Administrators took LPA on a physical plant tour of the facility. The facility has submitted a mitigation plan to the department.

The facility is a Residential Care Facility for the Elderly. During the facility tour, LPA advised Administrators that Protective Personal Equipment (PPE) should be readily available to staff in a central location. Staff demonstrated PPE supplies were easily accessible to LPA. LPA discussed benefits of fit-testing N95 masks for staff to avoid temporary staffing of nurses and other trained professionals.

LPA reviewed the Annual Mitigation Inspection Control Tool Module. Module was addressed with Administrators to satisfaction.

Exit interview was conducted. No deficiencies were cited. Report was emailed to Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE: DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/09/2021
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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