425802109-3-8-2022-29-AS-KKOS-CCC2TN-20220308164100

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425802109
Report Date: 03/08/2022
Date Signed: 03/08/2022 04:42:14 PM

Document Has Been Signed on 03/08/2022 04:42 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:	A CASA RHODA 2		FACILITY NUMBER:	425802109
ADMINISTRATOR:	DEMONTEVERDE, NORMA B		FACILITY TYPE:	740
ADDRESS:	165 SANTA ANA AVENUE		TELEPHONE:	(805) 964-4236
CITY:	SANTA BARBARA	STATE: CA	ZIP CODE:	93111
CAPACITY:	6	CENSUS: 5	DATE:	03/08/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Rhoda Demonteverde, Administrator		TIME COMPLETED:	04:10 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 Infection Control Inspection. The facility has submitted a Mitigation Plan to the Department. LPA arrived at 2:00 pm and was greeted by Staff 1 (S1) of the visit. At the time of arrival, there were two staff on duty and three (3) residents present. LPA informed staff of the visit. Rhoda Demonteverde, Director of Care and Norman Demonteverde, Administrator, arrived at the facility at approximately 2:05 pm. Entrance interview conducted. There are currently three (3) residents residing in the facility. The facility is one-story home to residents with a dementia diagnosis, mild cognitive impairment, and/or developmental delay. 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. First aid kit was observed to be complete. There is one fire extinguisher last serviced on 2/14/2022. The facility floor plan was reviewed with no changes noted. 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. There are 2 carbon monoxide alarms, 6 smoke alarms and one pull alarm that alerts the local fire department. The kitchen area was sufficiently stocked with two-day perishable and seven-day non-perishables. Snacks and beverages are available for Residents in the facility upon request. Frozen foods are properly wrapped and stored appropriately. LPA observed the kitchen cabinets, refrigerator, stove, and counters are clean. LPA observed the sharps are kept in a locked drawer. The kitchen trash and cleaning agents are kept in a locked cabinet in the laundry area. Medications are kept in a locked centrally stored cabinet. 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: 03/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022

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: A CASA RHODA 2	FACILITY NUMBER: 425802109
	VISIT DATE: 03/08/2022

NARRATIVE

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The backyard has a covered patio with outdoor furniture including cushioned chairs and tables. There are concrete walkways with garden plants and pots throughout the backyard. There are no bodies of water.
The recycling bin, green waste bin, and trash bins are standard bins with flip lids. A locked private staff room is located at the back of the home.
The 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.
The facility currently has three (3) residents each with a private room. There are two bathrooms for residents with access from the hallway, Each resident’s room has lights and nightstand lamps to provide sufficient lighting.
The bathrooms have secure grab bars. All staff have passed a criminal background clearance and have been properly associated to the facility.

Exit interview conducted. No deficiencies noted. No citations issued. Copy of report issued

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022

LIC809 (FAS) - (06/04)

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