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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850210
Report Date: 10/15/2025
Date Signed: 10/15/2025 03:53:49 PM

Document Has Been Signed on 10/15/2025 03:53 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 CAMBRIA WAYFACILITY NUMBER:
425850210
ADMINISTRATOR/
DIRECTOR:		ASEL TELMANFACILITY TYPE:
740
ADDRESS:803 CAMBRIA WAYTELEPHONE:
(818) 983-1002
CITY:SANTA BARBARASTATE: CAZIP CODE:
93105
CAPACITY: 6CENSUS: 6DATE:
10/15/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:01 PM
MET WITH:Asel Telman, AdminstratorTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced required Annual Inspection at the facility. LPA met with Asel Telman, Administrator and explained the purpose of the visit.

Entrance Interview Conducted:
The facility is a one-story Residential Care Facility for the Elderly (RCFE). The facility has been approved for six non-ambulatory residents of which two may be bedridden and maintains a hospice waiver for six residents.
There are currently 6 residents residing in the facility. Upon arrival, there were five residents in care with one caregiver and one administrator on duty. Three (3) residents are currently on hospice.
The facility consists of a living room, dining area, kitchen, and five bedrooms. Upon entrance, there is a walkway leading to the front door and garden areas. The front porch has a covered patio with available seating. The facility has a locked garage used for storage including the facility’s commercial generator. There are no fountains or bodies of water.
The entrance into the residence leads into the common living area from a hallway. The kitchen consists of a refrigerator, microwave, sink, stove, oven, dishwasher, and a toaster. Trash and recycling bins are kept in a pullout drawer. All required CCL posters and signage are posted near the entrance and in the hallway. Personnel files, Residents’ files, and medications are kept in locked cabinets in the kitchen area. All files and medications are inaccessible to residents in care. Sharps are kept in a locked kitchen drawer and are inaccessible to residents in care. Perishable foods for 2 days and non-perishable foods for 7 days are kept on hand for the residents.
The living room and dining area are furnished with adequate furnishings to sustain a capacity of six residents. First aid kits and a locked first aid supply cabinet are kept in the built-in locked cabinets located in the hallway. Please continue to 809-C, Pg 2

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Kristin Kontilis
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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 CAMBRIA WAY
FACILITY NUMBER: 425850210
VISIT DATE: 10/15/2025
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Bedroom 1 is a shared bedroom with a shared private bath. Bedrooms 2 and 3 are private bedrooms with private bathrooms. Bedrooms 4 and 5 are private bedrooms and share a bathroom off the hallway. Each bathroom has a sink, commode, and showers with grab bars.
Bedrooms 1 and 5 have been designated as bedridden bedrooms. Each bedridden bedroom has an exit/entrance door leading to the outdoor areas. Each exit/entrance door has a functioning door alarm.
Each resident’s bedroom has a bed, mattress, nightstand, chair, dresser, closet, and a motion detector for movement. Overhead lighting and lamps on the nightstands provide sufficient lighting in each bedroom. Hallways have night lights and ample lighting.
The laundry area and storage area for cleaning agents and chemicals is located in the locked garage.
The backyard consists of an umbrella, fenced, patio area with chairs and tables. The patio has built-in garden planters and walkways. The trash, recycling, and green waste cans are standardized cans located outside the facility.
There is a hard-wired dual carbon monoxide detector and smoke alarm system in every room and every hallway.
There are three fire extinguishers that were serviced on 2/18/2025. The fire extinguishers are located near the common area close to the bedrooms, kitchen, hallway, and in the garage.
LPA observed the facility’s comfortable room temperature upon arrival. Residents’ records, personnel documents and records of confidentiality are kept in a locked closet located in the kitchen area.
Residents records were reviewed. Admission agreements, needs and services plans, health screenings, and emergency contact information was on file and up to date for each resident. Medications are administered per Doctor’s orders.
Residents participate at will in various activities based on their individual interests and preferences, including bird watching, musical activities, joyful movement, and games (Dominoes, Bingo, and many others). Exercise classes on the premises are provided for the residents that include physical therapy, music, and singing.
Residents participate at will in outdoor activities such as spiritual/worship, socializing with family and friends, leisure drives and walks, and outside exercise. Volunteers from community organizations will assist residents in reading, arts and crafts activities, games, and seasonal celebrations.

Please continue to 809-C, Pg 3.

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Kristin Kontilis
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025
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 CAMBRIA WAY
FACILITY NUMBER: 425850210
VISIT DATE: 10/15/2025
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 Administrator’s certificate is current. Staff records reviewed with all trainings, health screenings, and personnel documents are current. All staff have received a criminal background clearance and are associated to the facility.

Exit interview conducted. No deficiencies noted; no citations issued. Copy of report issued at the time of the visit.

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Kristin Kontilis
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025
LIC809 (FAS) - (06/04)
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