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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425800511
Report Date: 09/28/2021
Date Signed: 09/28/2021 01:44:36 PM

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 NAOMIFACILITY NUMBER:
425800511
ADMINISTRATOR:RHONNA BUYCOFACILITY TYPE:
740
ADDRESS:855 N. PATTERSON AVE.TELEPHONE:
(805) 681-9567
CITY:SANTA BARBARASTATE: CAZIP CODE:
93111
CAPACITY:6CENSUS: 3DATE:
09/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Rhonna Buyco, AdministratorTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) K. Kontilis conducted an unannounced onsite one-year infection control annual visit to the above-named facility. Administrator Rhonna Buyco arrived at the facility at approximately 11:34 AM, LPA 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 main entrance to the facility. 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 at least once a day. All documentation is kept in a binder. The entry station has PPE gear, hand sanitizer, disinfecting wipes, and a thermometer.
LPA conducted a physical tour of the facility. This is a one-level home licensed as a Residential Care Facility for the Elderly (RCFE).
There are currently three residents residing in the facility. Upon arrival, there were two residents and one caregiver present. One (1) resident is currently on hospice.
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 kit was observed to be complete.
The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked. The facility was seen to be in good repair inside and outside. Fire inspection was conducted on May 6, 2021. The dual carbon monoxide/smoke alarms are hard wired and connected to the local fire department. Medications are kept in a locked centrally stored closet.
The backyard has a gazebo with outdoor furniture, and flower beds with paved walkways. There are no bodies of water. 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 temperature at 74 degrees Please continue to 809-C, Page 2.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
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 NAOMI
FACILITY NUMBER: 425800511
VISIT DATE: 09/28/2021
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Fahrenheit (F) with centralized heating and air conditioning. Hallways, bedroom doors and walls are in good repair.
The facility has 5 private bedrooms. Each resident’s room is furnished with overhead lights to provide sufficient lighting, nightstand, and a bed. Bedroom #2 has a private bathroom.
The facility has two shared bathrooms shared with access from the hallways. The bathrooms have secure grab bars.

Exit interview conducted. No deficiencies noted. No citations issued. Copy of report issued via email.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021
LIC809 (FAS) - (06/04)
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