425801380-11-15-2023-29-AS-KKOS-CXLU4C-20231115141454

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425801380
Report Date: 11/15/2023
Date Signed: 11/15/2023 02:15:10 PM

Document Has Been Signed on 11/15/2023 02:15 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-FAIRVIEW HOME		FACILITY NUMBER:	425801380
ADMINISTRATOR:	NOEMI E. BUYCO		FACILITY TYPE:	740
ADDRESS:	6181 VERDURA DRIVE		TELEPHONE:	(805) 964-3371
CITY:	GOLETA	STATE: CA	ZIP CODE:	93117
CAPACITY:	6	CENSUS: 6	DATE:	11/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:48 AM
MET WITH:	Sammy Ramirez, 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 one-year required Annual Inspection to the above-named facility. LPA was greeted by House Manager, Sammy Ramirez. Administrator Noemi Buyco arrived at approximately 12:05 pm. There are currently six (6) residents residing in the facility. At the time of arrival, there were three (3) residents in care and one (1) staff on duty. Three residents were temporarily out on individual outings. The facility is a Residential Care Facility for the Elderly (RCFE) and is home to non-ambulatory residents with a Dementia diagnosis and has an approved Hospice Waiver for three residents. Currently, there are no residents 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, bill of rights and Resident’s Rights. LPA inspected the one-story facility for fire safety, personal accommodations, and food service. The facility maintains a comfortable room temperature. The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, doors, floors and floor coverings were checked. There are two fire extinguishers on the premises last serviced on June 7, 2023. There is a total of 2 carbon monoxide detectors and 6 smoke alarms throughout the facility all in good working order. The kitchen is equipped with a stove/oven, refrigerator, dishwasher, microwave, coffee pot, and a toaster. Snacks and beverages are readily available for residents in care. LPA observed enough perishables for two days and non-perishables for seven days. LPA observed the kitchen area and dining areas to be clean. Cleaning agents and the toxic chemicals are kept in locked cabinet under the kitchen sink and in a locked cabinet in the laundry area. Medications are kept in a locked cabinet in the dining area. First aid kit is kept in a locked closet in the staff room. 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: 11/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

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-FAIRVIEW HOME	FACILITY NUMBER: 425801380
	VISIT DATE: 11/15/2023

NARRATIVE

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There are five private bedrooms and one shared bedroom. All bedrooms are adequately furnished with a bed, nightstand, overhead and/or table lamps. There is one bathroom off the hallway available to residents in care and one bathroom on the north side of the common area. Both of the bathrooms have non-skid flooring and grab bars for safety.
The backyard consists of paved walkways, patio tables with umbrellas, and well-manicured shrubs and trees. The recycling, trash, and green waste bins are standard bins.
Residents participate at will in various activities such as adult day programs, employment opportunities outside the facility, and outings to local eateries and shopping areas. Special events are held to celebrate birthdays, holidays, and personal recognitions and accomplishments.
The facility has proper cleaning and disinfectant sprays. Facility Administrator has a plan in place for when and whom to notify in an outbreak or other emergencies. Administrator will keep a line list of all vaccinated and tested staff/residents in care with dates/results.
Residents records were reviewed for health screenings, appraisals, and pre-appraisals. Personnel records were reviewed for criminal background clearance, health screenings, and trainings. Administrator’s Certificate is valid.
Technical Assistance: The facility's Emergency and Disaster Plan needs to be revised to include the following: Resident roster with each resident's date of birth; an appraisal of resident needs and services plan; a resident medication list with centrally stored medications; contact information for the responsible party and physician of each resident.
Administrator stated the Emergency and Disaster Plan will be revised by the end of today's business day (4:30 pm).

Exit interview conducted. Technical Assistance provided. 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: 11/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

LIC809 (FAS) - (06/04)

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