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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425800946
Report Date: 09/19/2022
Date Signed: 09/19/2022 06:23:12 PM


Document Has Been Signed on 09/19/2022 06:23 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 NAOMI-CATHEDRAL OAKS HOMEFACILITY NUMBER:
425800946
ADMINISTRATOR:RHONNA BUYCOFACILITY TYPE:
740
ADDRESS:5618 CATHEDRAL OAKSTELEPHONE:
(805) 964-7925
CITY:GOLETASTATE: CAZIP CODE:
93117
CAPACITY:6CENSUS: 6DATE:
09/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:56 PM
MET WITH:Naomi Buyco, Licensee/AdministratorTIME COMPLETED:
06:40 PM
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On 9/19/22 at 4:55 pm, Licensing Program Analyst (LPA) Chavez conducted an unannounced on-site annual infection control visit to the facility listed above. LPA met with Staff #1 (S1) and explained the purpose of the visit. At 5:25 pm, Naomi Buyco, Licensee/Administrator, arrived at the facility, and LPA and explained the purpose of the visit.

LPA toured the facility with S1 and observed the following: The facility has soap and paper towels for residents’ bathrooms and handwashing signage. The fire extinguisher is located in the kitchen. The extinguisher is fully charged and was inspected on 7/20/22. The facility has infection control signage at the front door and signage throughout the facility on handwashing, cough etiquette and use of masks. Upon entry to the facility, LPA was screened, however, the licensee did not have a visitor policy posted at the front door. LPA will send signage, and Licensee will send a photo of the signage posted by end of day 9/20/22. Staff were wearing masks. The two (2) gates on each side of the facility do not have automatic closing mechanisms. Licensee will install and send videos of both gates automatically closing by end of day Monday, 9/26/22.

At 5:40 pm LPA conducted the Infection Control mitigation module with the Licensee.

Exit interview conducted and the report emailed to the Licensee.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2022
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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