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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425800511
Report Date: 08/16/2023
Date Signed: 08/16/2023 01:51:28 PM


Document Has Been Signed on 08/16/2023 01:51 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 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:
08/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Rhonna Buyco, Administrator and Mariaaires Yaya, House ManagerTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced required Annual Inspection to the above-named facility. Administrator Rhonna Buyco arrived at the facility at approximately 11:50 AM, LPA explained the purpose of the visit.
Entrance interview conducted.
LPA conducted a physical tour of the facility. This is a one-story home licensed as a Residential Care Facility for the Elderly (RCFE) and maintains a service contract with Tri-Counties Regional Center for 2 residents. It is home to residents who may have a dementia diagnosis and/or developmentally/intellectually disabled. The facility’s fire clearance has been approved for 6 non-ambulatory residents and 1 bedridden resident. The facility has a hospice waiver for 1 resident.
There are currently three residents residing in the facility, none of which are on hospice at this time.
Upon arrival, the house manager/caregiver was on duty. Residents in care were out in the community attending adult day programs and work programs.
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, doors, floors and floor coverings were checked. The kitchen, living room, and dining area are neat and clean.
Fire inspection was conducted on April 7, 2023. The dual carbon monoxide/smoke alarms are hard wired and connected to the local fire department.
The backyard has a gazebo with outdoor furniture, and flower beds with paved walkways. There are no bodies of water. The backyard is conducive for visits and activities held outdoors. The recycling bin, green waste bin, and trash bins are standard bins with flip lids. The facility maintains a comfortable temperature at 74 degrees Fahrenheit (F) with centralized heating and air conditioning. Hallways, bedroom doors and walls are in good repair. 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: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2023
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: 08/16/2023
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 The facility has 5 bedrooms for 5 residents. Bedroom #2 has a private bathroom. Each resident’s room is furnished with overhead lights to provide sufficient lighting.
There are three shared bathrooms—one shared bathroom is off the hallway located at the front of house leading from the living room. Two bathrooms are off the second hallway leading from the dining area. All residents have access to the three shared bathrooms.
Residents participate at will in activities out in the community attending day programs, work programs, and family visits. In the facility, they participate individually and in groups with exercising activities, puzzles, social conversations, special celebrations, holiday celebrations, and excursions to local eateries and local parks.
Residents’ records were reviewed and all records are up-to-date. Personnel records were reviewed and records and trainings are up-to-date. All persons associated with the facility have a criminal record clearance and have been properly associated to the facility.

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

DATE: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023
LIC809 (FAS) - (06/04)
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