425801782-5-16-2023-29-AS-KKOS-CRVSU4-20230516141030

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425801782
Report Date: 05/16/2023
Date Signed: 05/16/2023 02:10:42 PM

Document Has Been Signed on 05/16/2023 02:10 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 - BRADFORD HOME		FACILITY NUMBER:	425801782
ADMINISTRATOR:	NOEMI E. BUYCO		FACILITY TYPE:	740
ADDRESS:	7779 BRADFORD DRIVE		TELEPHONE:	(805) 685-2625
CITY:	GOLETA	STATE: CA	ZIP CODE:	93117
CAPACITY:	6	CENSUS: 0	DATE:	05/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:10 PM
MET WITH:	Noemi Buyco, Administrator		TIME COMPLETED:	02:45 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 Annual Required visit and inspection of the facility. LPA arrived at 12:10 pm and was greeted by Administrator Noemi Buyco and explained the purpose of the visit. At the time of arrival, Administrator and Administrator’s spouse were present. Currently there are no residents residing in the facility. Entrance interview conducted. The facility is home to six (6) non-ambulatory residents. The facility is a two-story home consisting of a living room, dining room, kitchen, and four (4) bedrooms. The laundry room is located in the garage with no access to residents. A tour of the physical environment and accommodations were assessed. The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked. The kitchen was observed to be clean and sanitary. The living room and dining areas are neat and clean. The dining area is located next to the kitchen area. Access into the garage area is available through the dining area. The facility maintains a comfortable temperature at 72 degrees Fahrenheit (F). Hallways, bedroom doors and walls are in good repair. Bedroom #1 is a shared bedroom with a private bathroom. Bedrooms 2, 3, and 4 share a bathroom with access from the hallway. A fire extinguisher is located in the entry way near the front entrance into the facility. The fire extinguisher was serviced on August 16, 2023. There are five (5) dual smoke alarms/carbon monoxide detectors throughout the facility. Please continue to 809-C.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

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 - BRADFORD HOME	FACILITY NUMBER: 425801782
	VISIT DATE: 05/16/2023

NARRATIVE

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The backyard has a covered patio and wheelchair ramp to access the patio area. There is a double storage area located in the backyard adjacent from the patio area. Personnel and resident records are kept in a locked storage unit.
Staff records were reviewed. All staff are 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: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

LIC809 (FAS) - (06/04)

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