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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425800669
Report Date: 07/17/2024
Date Signed: 07/17/2024 02:34:19 PM


Document Has Been Signed on 07/17/2024 02:34 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 ORQUIOLAFACILITY TYPE:
740
ADDRESS:4744 AVALON AVENUETELEPHONE:
(805) 964-6339
CITY:SANTA BARBARASTATE: CAZIP CODE:
93110
CAPACITY:6CENSUS: DATE:
07/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:John OrquiolaTIME 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. Upon arrival, LPA was greeted by Staff 1 (S1). Administrator John Urquiola arrived at approximately 11:12 AM. At the time of arrival, there were 4 residents in care and 1 staff on duty.
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, Resident’s Personal Rights, and Long Term Care Ombudsman poster. 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 facility was seen to be in good repair inside and outside. Fire inspection was most recently conducted on 6/10/2024. There are eleven (11) dual carbon monoxide detectors/smoke alarms throughout the facility all in good working order.
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 are stored in a cabinet located in the dining area. At approximately 11:03 AM, LPA observed the medication cabinet was not locked. S1 locked the cabinet immediately upon LPA’s request.
At approximately 12:15 pm, medication inventory conducted revealed the following: Resident 1’s (R1’s) prescribed Levothyroxine 75MCG count had two (2) extra tablets, Losartan 100MG had one (1) extra tablet; Resident 2’s (R2’s) prescribed Escitalopram 10MG had one (1) extra tablet and Losartan Potassium 100MG was short one (1) tablet.

Please continue to 809-C, Pg 2.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2024
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: 07/17/2024
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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 closet in the hallway.
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 four private bedrooms available for four 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.
Resident’s records are current. Personnel records and training records are current.
All persons associated with the facility have a criminal record clearance and have been properly associated to the facility.

The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in additional civil penalties.



Exit interview conducted. A copy of the report and appeal rights 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: 07/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 07/17/2024 02:34 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
87465(c)(2) Incidental and Medical Care: ....Once ordered by the physician the medication is given according to the physician's directions.
This requirement has not been met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above when there was an unexplainable overcount of two (2) of R1’s prescribed medications, one (1) of R2’s medications, and one (1) unexplainable undercount of R2’s medication which poses an immediate health and safety risk to residents in care.
POC Due Date: 07/19/2024
Plan of Correction
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Administrator agrees to submit a written statement of understanding of CCR 87465 in its entirety.
Type A
Section Cited
CCR
87465(h)(2)
87465(h)(2) Incidental Medical and Dental Care Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with regulation above when LPA observed the medication cabinet was unlocked which poses an immediate risk to residents in care.
POC Due Date: 07/19/2024
Plan of Correction
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S1 locked the medication cabinet upon LPA's request. Administrator agrees to submit a written statement of understanding of CCR 87465 in its entirety.
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 BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2024
LIC809 (FAS) - (06/04)
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