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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850481
Report Date: 07/23/2021
Date Signed: 07/23/2021 03:52:52 PM

Document Has Been Signed on 07/23/2021 03:52 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:ABOVE ALL CARE, LLCFACILITY NUMBER:
425850481
ADMINISTRATOR:ANDREICHENKO, VIKTORIIAFACILITY TYPE:
740
ADDRESS:4532 NUECES DRIVETELEPHONE:
(805) 403-7455
CITY:SANTA BARBARASTATE: CAZIP CODE:
93110
CAPACITY: 6CENSUS: 6DATE:
07/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 AM
MET WITH:Valentina Polunets, AdministratorTIME COMPLETED:
02:55 PM
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At 12:30 PM, Licensing Program Analyst (LPA) Toan Luong initiated facility risk assessment questionnaire with Administrator Valentina Polunets. LPA conducted an unannounced on-site one year infectious control annual visit to the facility. LPA met with Administrators Valentina Polunets and Viktoria Andreichenko and explained the purpose of the visit.

Administrator Valentina Polunets took LPA on a physical plant tour of the facility. The facility has submitted an approved mitigation plan to the department.

The facility is a Residential Care Facility for the Elderly. During the facility tour, LPA advise Administrator to post various infection control signs. Signs include visitation signs outside facility, cough/sneeze etiquette, reporting of acute respiratory illness, CDSS PINs. Administrator posted signs prior LPA's departure in a visible location. LPA discussed benefits of fit-testing N95 masks for staff to avoid temporary staffing of nurses and other trained professionals and steps facility may take to fit-test staff.

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 the Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE: DATE: 07/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2021
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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