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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801380
Report Date: 10/02/2024
Date Signed: 10/02/2024 02:15:50 PM


Document Has Been Signed on 10/02/2024 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 HOMEFACILITY NUMBER:
425801380
ADMINISTRATOR:NOEMI E. BUYCOFACILITY TYPE:
740
ADDRESS:6181 VERDURA DRIVETELEPHONE:
(805) 964-3371
CITY:GOLETASTATE: CAZIP CODE:
93117
CAPACITY:6CENSUS: 5DATE:
10/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Rhonna Buyco, AdministratorTIME COMPLETED:
03:45 PM
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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 12:41 pm.
There are currently five (5) residents residing in the facility. At the time of arrival, there were two (2) 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. The facility has a service contract with Tri-Counties Regional Center.

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 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 August 8, 2024. There are 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 BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:
DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2024
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-FAIRVIEW HOME
FACILITY NUMBER: 425801380
VISIT DATE: 10/02/2024
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There are five private bedrooms and one shared bedroom. All bedrooms are adequately furnished with a bed, night stand, 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. Staff and residents share gardening activities that include vegetables and fruit. Special events are held to celebrate birthdays, holidays, as well as personal recognition and accomplishments.
Facility Administrator has a plan in place for when and whom to notify in an outbreak or other emergencies.
Residents records were reviewed for health screenings, appraisals, and pre-appraisals. Medications are given as prescribed. Residents’ financial statements were accurate and accounted for.
Personnel records were reviewed for criminal background clearance, health screenings, and trainings. Administrator’s Certificate is valid.

Exit interview conducted. Copy of report issued at the time of the visit via email by request of Administrator.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024
LIC809 (FAS) - (06/04)
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