425800669-8-2-2022-29-AS-KKOS-CGWVKJ-20220802163026

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425800669
Report Date: 08/02/2022
Date Signed: 08/02/2022 04:30:55 PM

Document Has Been Signed on 08/02/2022 04:30 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:	HOMECARE CASA LINDA, INC.		FACILITY NUMBER:	425800669
ADMINISTRATOR:	JOHN ORQUIOLA		FACILITY TYPE:	740
ADDRESS:	4744 AVALON AVENUE		TELEPHONE:	(805) 964-6339
CITY:	SANTA BARBARA	STATE: CA	ZIP CODE:	93110
CAPACITY:	6	CENSUS: 2	DATE:	08/02/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	John Orquiola, Administrator		TIME COMPLETED:	04:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	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 2:00 pm and was greeted by Staff 1 (S1). Administrator John Urquiola arrived at approximately 2:23 pm. At the time of arrival, there were 3 residents in care and 2 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. There are no residents currently on hospice. 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 two-story facility for fire safety, personal accommodations, and food service. First aid kit was observed to be complete. Entrance interview conducted. 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 most recently conducted on 6/28/2022. There are ten (10) dual carbon monoxide detectors/smoke alarms throughout the facility. The kitchen area was sufficiently stocked with two-day perishables and seven days of non-perishables. Snacks and beverages are readily available for Residents. LPA observed the kitchen cabinets, refrigerator, stove, and counters are clean. Medications and first aid kit are kept in a locked cabinet in the dining area. Please continue to 809-C.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022

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: HOMECARE CASA LINDA, INC.	FACILITY NUMBER: 425800669
	VISIT DATE: 08/02/2022

NARRATIVE

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Residents participate independently in games, music entertainment, neighborhood walks, and one-on-one socialization among the residents and staff.
The front yard is well-maintained and consists of walkways and garden areas. The backyard is well-maintained and has a paved covered patio, sitting areas, and garden areas with a paved walkway surrounding the parameter of the yard. The backyard is conducive for outdoor visitation.
The recycling bin, green waste bin, and trash bins are standard bins with flip lids. Chemicals and cleaning supplies are kept in a locked cabinet under the kitchen sink.
The kitchen, living room, and dining area are neat and clean. The facility maintains a comfortable temperature. Hallways, bedroom doors, and walls are in good repair.
There are six private bedrooms available for six residents. There is a live-in staff room off the hallway that remains locked throughout the day and night.
There are two bathrooms each with a shower room located in the hallway with access available to all residents. The bathrooms have secure grab bars and no skid flooring.
All persons associated with the facility have a criminal record clearance and have been properly associated to the facility.

Exit interview conducted. No citations issued. A copy of this report has been issued.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022

LIC809 (FAS) - (06/04)

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