425800946-8-16-2023-29-AS-KKOS-CURT4F-20230816142348

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425800946
Report Date: 08/15/2023
Date Signed: 08/16/2023 02:24:04 PM

Document Has Been Signed on 08/16/2023 02:24 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:	08/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Rhonna Buyco, Administrator; Henry Miranda, House Manager		TIME COMPLETED:	04:00 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. Administrator Rhonna Buyco and House Manager, Henry Miranda arrived at the facility at approximately 11:55 AM, 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. Upon arrival, there were two residents and one caregiver present. 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 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 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: 08/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023

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: 08/15/2023

NARRATIVE

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The facility has 3 bedrooms for 6 residents. Each resident’s room is furnished with overhead lights to provide sufficient lighting, nightstand, and a bed.
The facility has two shared bathrooms shared with access from the hallways.
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: 08/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023

LIC809 (FAS) - (06/04)

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