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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801989
Report Date: 01/22/2025
Date Signed: 01/22/2025 02:10:42 PM

Document Has Been Signed on 01/22/2025 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:EDELWEISS HOMEFACILITY NUMBER:
425801989
ADMINISTRATOR/
DIRECTOR:		MILDRED HUG-DEMONTEVERDEFACILITY TYPE:
740
ADDRESS:294 PEBBLE HILL DRIVETELEPHONE:
(805) 284-5870
CITY:SANTA BARBARASTATE: CAZIP CODE:
93111
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
01/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Mildred Hug, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced on-site one-year Annual Inspection to the above-named facility. LPA was greeted by Staff 1 (S1) and Staff 2 (S2). At the time of arrival, there were four (4) residents in care and two (2) staff on duty. Administrators Mildred Hug and Andre Hug arrived at approximately 12:45 pm.

Entrance Interview Conducted:
The facility is a Residential Care Facility for the Elderly (RCFE) and is home to non-ambulatory residents with a Dementia diagnosis, and has a Hospice Waiver for four residents, and a fire clearance for one bedridden resident. Currently, there are two (2) residents on hospice.
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 11/19/2024. 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.

Please continue to 809-C.

Kelly BurleyTELEPHONE: (805) 562-0413
Kristin KontilisTELEPHONE: (805) 689-2787
DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/22/2025
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: 01/22/2025
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 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 with hallway access available to all residents. The bathrooms have secure grab bars and no skid flooring.
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 sloped 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.
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.
Administrator's certificate is current.

Exit interview conducted. No citations issued. A copy of this report was issued at the time of the visit.

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

DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025
LIC809 (FAS) - (06/04)
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