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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850481
Report Date: 07/12/2022
Date Signed: 07/13/2022 08:25:33 AM

Document Has Been Signed on 07/13/2022 08:25 AM - 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:
07/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Viktoria Andreichenko, AdministratorTIME COMPLETED:
05:30 PM
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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced on-site one-year Infection Control Inspection visit to the above-named facility. LPA arrived at 1:25 pm was greeted by Staff 1 (S1). Administrator Victoria Andreichenko arrived at approximately 1:45 pm. Valentyna Polunets, Co-Administrator arrived at approximately 1:55 pm. At the time of arrival, there were 5 residents in care and 1 staff on duty.
A Mitigation Plan has been submitted to CCLD. LPA explained the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) and is home to non-ambulatory residents with a dementia diagnosis.
Entrance interview conducted:
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. First aid kits were observed to be complete.
Entrance interview conducted.
The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, doors, floors and floor coverings were checked. There is one fire extinguisher on the premises last serviced on 7/23/2021. There is a total of one dual smoke/carbon monoxide alarm and six smoke alarms throughout the facility all in good working order.
Snacks and beverages are available for residents in care upon request. LPA observed the kitchen cabinets, refrigerator, stove, and counters are clean. Cleaning agents and the toxic chemicals are kept in a locked garage. Medications are kept in a locked centrally stored cabinet. Sharps are kept in a locked cabinet in the kitchen.
The backyard has a covered patio with outdoor furniture, a gazebo, paved walkways, and a locked shed. The front yard is conducive for outdoor for outdoor visitation. The front yard has paved walkways and garden areas.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2022
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: ABOVE ALL CARE, LLC
FACILITY NUMBER: 425850481
VISIT DATE: 07/12/2022
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LPA observed a vase approximately 3 feet tall and 18 inches in diameter with standing water located in the garden area of the front entrance into the facility. The recycling bin, green waste bin, and trash bins are standard bins with flip lids.
The living room and dining area are neat and clean. The facility maintains a comfortable room temperature measured at 1:45 pm. Hallways, bedroom doors and walls are in good repair.
The facility has six (6) bedrooms for a capacity of six residents. Bedroom #1 has a private bathroom. There three bathrooms available for residents located off the hallways of the facility. All of the bedrooms are furnished with lights and nightstand lamps to provide sufficient lighting.
There are two residents currently on hospice. Hospice information was reviewed for Resident 1 (R1) and Resident 2 (R2). Upon record review, LPA determined that CCL did not receive a hospice notification for R1. Upon record review and interviews conducted, hospice notification for R1 was submitted to CCL with no identifying information including but not limited to facility name, facility number, and facility address.
All persons associated with the facility have a criminal background clearance.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):



Exit interview conducted. Due to technical difficulties, report was sent to Administrator for signature. Copy of report and appeal rights issued via email.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/13/2022 08:25 AM - It Cannot Be Edited


Created By: Kristin Kontilis On 07/12/2022 at 04:39 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ABOVE ALL CARE, LLC
FACILITY NUMBER: 425850481

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.1(a)(2)
87468.1 (a)(2) Personal Rights of Residents in all Facilities; To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews and observation the licensee did not ensure staff were following infection control guidelines which poses an immediate health, safety and personal rights risk to residents in care.
POC Due Date: 07/13/2022
Plan of Correction
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Administrator agrees to document and retain screening information including as stated in PIN 21-40-ASC and PIN 22-07-ASC (documentation to include first, last name, date and time of screening, contact information, vaccination information for visitors, COVID test results, testing date, testing exemption if applicable.)
Type A
Section Cited
CCR
87632(d)(2)

87632(d)(2) Hospice Waiver: The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services. The notice shall include the resident's name and date of admission to the facility and the name and address of the hospice.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interviews conducted, the licensee did not comply with the section cited above in 1 out of 1 hospice notification was not submitted to CCL which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/13/2022
Plan of Correction
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Administrator agrees to submit hospice notification with required information including but not limited to facility name, facility number, facility address, hospice admission date, hospice agency address, and telephone number within five (5) days of resident(s) placed on hospice.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kelly Burley
LICENSING EVALUATOR NAME:Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2022


LIC809 (FAS) - (06/04)
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