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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850059
Report Date: 11/16/2021
Date Signed: 11/16/2021 01:54:40 PM

Document Has Been Signed on 11/16/2021 01:54 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 ST. JAMESFACILITY NUMBER:
425850059
ADMINISTRATOR:DZHEENTAEVA, ASELFACILITY TYPE:
740
ADDRESS:2215 ST. JAMES DRIVETELEPHONE:
(805) 845-6405
CITY:SANTA BARBARASTATE: CAZIP CODE:
93105
CAPACITY: 6CENSUS: DATE:
11/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:07 PM
MET WITH:Asel Dzheentaeva-Telman, AdministratorTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced onsite one-year infection control annual visit to the above-named facility. LPA met with Asel Dzheentaeva-Telman, Administrator and explained the purpose of the visit.
Entrance interview conducted.
The facility has submitted a Mitigation Plan to the Department. The facility has an entry station at the front door. Upon entry, staff, visitors, and clients who have returned from an outing are required to sign-in, complete a symptom questionnaire, and have a temperature screening. All documentation is kept in a binder near the main entrance. The entry station has PPE gear consisting of masks, gloves, gowns, thermometer, hand sanitizer, and disinfecting wipes.
LPA conducted a physical tour of the facility. A walkway to the front door is the main entrance into the facility. The facility consists of a: Living room, dining area, kitchen, four bedrooms (two private and two shared), a locked staff room, laundry area, and a locked garage. Laundry supplies and equipment are kept in the locked garage.
Residents' bedrooms have a bed, mattress, nightstand, chair, dresser, and closet. Overhead lighting and lamps provide sufficient lighting in each bedroom. Bedrooms 1 and 2 are shared bedrooms with a private bathroom in each bedroom. Bedrooms 1 and 2 have an outdoor exit with an alarm. Bedrooms 3 and 4 are private bedrooms with one shared bathroom.
The backyard consists of a covered porch, sitting area, and a swimming pool in a locked fenced area.
The resident records and staff records are kept in a locked kitchen cabinet. First Aid kit(s) and medications are kept in a locked cabinet located in the kitchen. LPA observed smoke detectors and carbon monoxide detectors are hard-wired and directly connected with the local fire department. Fire extinguishers were serviced on 3/3/2021. Fire clearance is approved for 6 non-ambulatory residents of which 2 may be bedridden.
Emergency food, water, emergency PPE gear is kept in the locked garage.

Exit interview conducted, no citations issued. Copy of report issued via email.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2021
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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