425801989-1-28-2022-29-AS-KKOS-CB4VF6-20220128152325

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425801989
Report Date: 01/28/2022
Date Signed: 01/28/2022 03:23:58 PM

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:	EDELWEISS HOME		FACILITY NUMBER:	425801989
ADMINISTRATOR:	MILDRED HUG-DEMONTEVERDE		FACILITY TYPE:	740
ADDRESS:	294 PEBBLE HILL DRIVE		TELEPHONE:	(805) 284-5870
CITY:	SANTA BARBARA	STATE: CA	ZIP CODE:	93111
CAPACITY:	6	CENSUS: 4	DATE:	01/28/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Mildred Hug, Administrator		TIME COMPLETED:	03:10 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 Infection Control Inspection of the facility. LPA arrived at 1:30 PM and was greeted by Mildred Hug, Administrator and explained the purpose of the visit. One (1) staff member and Co-Administrator Andre Hug were on duty with four (4) residents present at the time of LPA's arrival. Entrance interview conducted. There are currently four (4) residents residing in the facility. The facility is a one-story Residential Care Facility for the Elderly (RCFE). There are currently three residents on hospice. One resident is currently bedridden. 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 physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked. The facility was seen to be in good repair inside and outside. Fire inspection was current. The facility has seven (7) dual carbon monoxide/smoke alarms that are hardwired throughout the facility. The kitchen area was sufficiently stocked with two-day perishables and seven days of non-perishables. Snacks and beverages are readily available for Residents. Frozen foods are properly wrapped and stored appropriately. LPA observed the kitchen cabinets, refrigerator, stove, and counters are clean. Medications, First Aid kit, and additional first aid supplies are kept in a locked centrally stored cabinet. First aid kit was observed to be complete. Residents participate independently in reading activities, games, and walks. The front yard consists of slopped concrete walkways and potted plants. The backyard has a patio with walkways, outdoor furniture and potted plants. The recycling bin, green waste bin, and trash bins are standard bins with flip lids. A locked garage is located at the back of the home. 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: 01/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2022

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: EDELWEISS HOME	FACILITY NUMBER: 425801989
	VISIT DATE: 01/28/2022

NARRATIVE

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The kitchen, living room, and dining area are neat and clean. The facility maintains a comfortable room temperature. Hallways, bedroom doors, and walls are in good repair.
There are five private bedrooms. Each bedroom has a bed, nightstand, and lights and/or lamps to provide sufficient lighting.
There are two bathrooms with hallway access available to all residents. The bathrooms have secure grab bars and no skid flooring.
The kitchen is equipped with a stove top, built-in oven, refrigerator, dishwasher, microwave, toaster, and a coffee maker.
A background clearance has been completed for all staff members.
Exit interview conducted. No citations issued. A copy of this report has been issued via email.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2022

LIC809 (FAS) - (06/04)

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