425801989-12-6-2023-29-AS-KKOS-CY9UY3-20231206145917

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425801989
Report Date: 12/06/2023
Date Signed: 12/06/2023 03:00:06 PM

Document Has Been Signed on 12/06/2023 03:00 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:	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: 5	DATE:	12/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:10 PM
MET WITH:	Mildred Hug, Administrator		TIME COMPLETED:	03:45 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 on-site one-year Annual Inspectiont to the above-named facility. LPA was greeted by Co-Administrators Mildred Hug and Andre Hug. At the time of arrival, there were five (5) residents in care and two (2) administrators on duty. The facility is a Residential Care Facility for the Elderly (RCFE) and is home to non-ambulatory residents with a Dementia diagnosis, a Hospice Waiver for four residents, and a fire clearance for one bedridden resident. Currently, there are three (3) 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 12/6/2023. There is a total of 8 dual carbon monoxide detector/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. 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. Cleaning agents and the toxic chemicals are kept in locked supply cabinet in the garage. Medications, First Aid kit, and additional first aid supplies are kept in a locked centrally stored cabinet. Medications are given as per Physician’s directions. There are three private bedrooms and one shared bedroom. All bedrooms are adequately furnished with a bed, nightstand, overhead and/or table lamps. There are two bathrooms off the hallway available to residents in care. Each bathroom has non-skid flooring and grab bars for safety. 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: 12/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023

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: EDELWEISS HOME	FACILITY NUMBER: 425801989
	VISIT DATE: 12/06/2023

NARRATIVE

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Residents participate at will in sing-alongs, reading activities, games, walks, and excursions to the local eateries and local attractions.
The front yard consists of slopped concrete walkways and potted plants. The backyard has a patio with outdoor furniture and potted plans. The recycling bin, green waste bin, and trash bins are standard bins with flip lids. A locked garage is located on the side of the home.
There are three private rooms and one shared room. Each bedroom has a bed, nightstand, and lights 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.
Residents’ files were reviewed. LPA noted that on file for each resident was the following: Physician’s Reports, Admission Agreements, Medical Assessments, Identification and Emergency information, Appraisals/Needs Service Plan, and Medication Administration Records (MARs).
Staff files reviewed had criminal record statements, health screenings, current first aid certificates, and all required training. All persons associated with the facility have criminal record clearance.
Administrators' certificates are current.

Exit interview conducted. No citations issued. A copy of this report has been issued.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023

LIC809 (FAS) - (06/04)

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