425800946-8-7-2024-29-AS-KKOS-D7WRTL-20240807131830

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425800946
Report Date: 08/07/2024
Date Signed: 08/07/2024 01:19:22 PM

Document Has Been Signed on 08/07/2024 01:19 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 HOME		FACILITY NUMBER:	425800946
ADMINISTRATOR:	RHONNA BUYCO		FACILITY TYPE:	740
ADDRESS:	5618 CATHEDRAL OAKS		TELEPHONE:	(805) 964-7925
CITY:	GOLETA	STATE: CA	ZIP CODE:	93117
CAPACITY:	6	CENSUS: 6	DATE:	08/07/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Rhonna Buyco, Administrator		TIME COMPLETED:	01:30 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 required Annual Inspection to the above-named facility. Upon arrival, there were two residents in care and two staff on duty. Four residents were out in the community attending day programs. Administrator Rhonna Buyco arrived within 10 minutes after LPA’s arrival. LPA explained the purpose of the visit. Entrance interview conducted. LPA conducted a physical tour of the facility. This is a one-level home licensed as a Residential Care Facility for the Elderly (RCFE). The facility is home to residents who are non-ambulatory and has a hospice waiver for 2 residents. There are currently six residents residing in the facility. There is one resident currently on hospice. All residents currently receive services from Tri-Counties Regional Center (TCRC). A tour of the physical environment and accommodations were assessed, and the following was noted: LPA observed the required posting of the complaint poster 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 living room and dining area are neat and clean. Fire inspection was conducted on August 7, 2024. The dual carbon monoxide/smoke alarms are hard wired and in good working order. 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 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, Pg 2.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024

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: CASA NAOMI-CATHEDRAL OAKS HOME	FACILITY NUMBER: 425800946
	VISIT DATE: 08/07/2024

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The facility has 3 shared bedrooms for 6 residents. Each resident’s room is furnished with overhead lights to provide sufficient lighting, nightstand, and a bed. There are two bathrooms available to all residents in care. Bathroom #1 is a full bathroom located off the hallway near the residents’ shared rooms. Grab bars are secure. Bathroom #2 is a half-bath with secured grab bars.
Residents participate at will in individualized activities such as art activities, karaoke, outdoor barbeques, special holiday celebrations, individual recognitions, as well as excursions to local eateries and day trips to other communities.
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 Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024

LIC809 (FAS) - (06/04)

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