425801008-9-18-2023-29-AS-KKOS-CVSV94-20230918161343

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425801008
Report Date: 09/18/2023
Date Signed: 09/18/2023 04:14:49 PM

Document Has Been Signed on 09/18/2023 04:14 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:	ALAMEDA HOUSE		FACILITY NUMBER:	425801008
ADMINISTRATOR:	NICHOLAS PAPAGEORGE		FACILITY TYPE:	735
ADDRESS:	7167 ALAMEDA AVENUE		TELEPHONE:	(805) 685-1111
CITY:	GOLETA	STATE: CA	ZIP CODE:	93117
CAPACITY: 6		CENSUS: 6	DATE:	09/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Jennifer Goddard, Co-Administrator		TIME COMPLETED:	04:30 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. LPA arrived at 1:20 PM and was greeted by Staff 1 (S1). Co-Administrators Jennifer Goddard and Nick Pappageorge arrived at approximately 1:55 pm. At the time of arrival, there were 6 clients in care and 1 staff on duty. LPA explained the purpose of the visit. The facility is a one-story home licensed as an Adult Residential Facility (ARF) for adults with a mental illness diagnosis and contracted with Santa Barbara County Behavioral Wellness Program. LPA toured facility with Staff 1. 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 facility for fire safety, personal accommodations, and food service. Fire extinguisher was last serviced on 8/11/2023. 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. The carbon monoxide alarm and smoke alarms are in good working order. Medications, First aid kit, and additional first aid supplies are kept in a locked office in a locked centrally stored cabinet. Medications are given as per Physician’s directions. First aid kit was observed to be complete. Residents participate at will in activities such as but not limited to activities with the mental wellness center (meditation groups, journaling, computer skills, life enrichment skills, community meetings, special celebrations, and off-site training at the mental wellness center). Residents also participate independently in arts and crafts, excursions to the local eateries, entertainment places, walks, and places of worship. Each resident has an assigned cooking day which includes preparing main meals for all residents and staff. Independently residents prepare their breakfast and lunch. Residents are assigned a weekly chore on a rotation basis. Each resident has an assigned laundry day for their individual laundry needs. Please continue to 809-C, Pg 2.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2023

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: ALAMEDA HOUSE	FACILITY NUMBER: 425801008
	VISIT DATE: 09/18/2023

NARRATIVE

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The front yard consists of paved walkways and an open porch. The backyard is an open area with chairs and a basketball hoop. A locked garage is located at the back of the home. The recycling bin, green waste bin, and trash bins are standard bins with flip lids kept in a locked gate next to the garage.
The kitchen, living room, and dining area are neat and clean and maintain a comfortable room temperature.
There are three (3) shared bedrooms for six residents. Each bedroom has two (2) single beds, nightstands, and lights and nightstand lamps to provide sufficient lighting.

There are two bathrooms shared by the residents. Bathroom #1 is located between the dining area and Bedroom #1. Bathroom #2 is located in the hallway near Bedrooms #2 and #3. The bathrooms have secure grab bars.

Residents’ files were reviewed. LPA noted that on file for each resident was the following: Physician's Reports, Admission Agreements, Medical Assessments, Health Screening, Identification and Emergency information, Appraisals/Needs Service Plan, and Medication Accounting Records (MARs).
Staff files reviewed had criminal background clearances, health screenings, current first aid certificates, and all required training.

Exit interview conducted. No deficiencies noted. Copy of report issued at the time of the visit.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2023

LIC809 (FAS) - (06/04)

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