425802110-3-9-2022-29-AS-KKOS-CCD2T3-20220309164004

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425802110
Report Date: 03/09/2022
Date Signed: 03/09/2022 04:41:00 PM

Document Has Been Signed on 03/09/2022 04:41 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 3		FACILITY NUMBER:	425802110
ADMINISTRATOR:	DEMONTEVERDE, NORMAN RHODE		FACILITY TYPE:	740
ADDRESS:	126 SANTA ANA AVENUE		TELEPHONE:	(805) 683-0980
CITY:	SANTA BARBARA	STATE: CA	ZIP CODE:	93111
CAPACITY:	6	CENSUS: 6	DATE:	03/09/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:06 AM
MET WITH:	Rhoda Demonteverde, Director of Care, Norman Demonteverde, Co-Administrator		TIME COMPLETED:	02:15 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 Inspection and Infection Control Inspection of the facility. A mitigation plan has been submitted to CCL. LPA arrived at 1:06 pm and was greeted by Staff 1 (S1) and explained the purpose of the visit. At the time of arrival, there were two (2) staff on duty. Four (4) residents were present and two (2) residents were attending an adult day program. LPA informed staff of the visit. Rhoda Demonteverde and Norman Demonteverde, Co-Administrators arrived at the facility at approximately 1:10 pm. Entrance interview conducted. There are currently six (6) residents residing in the facility. The facility is home to residents with a dementia diagnosis, mild cognitive impairment, and/or developmental delay. There is one (1) resident currently on hospice. There are ambulatory and non-ambulatory residents. The facility contracts with Tri-Counties Regional Center. 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. 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 serviced 2/14/2022. LPA observed two (2) carbon monoxide alarms, seven (7) smoke alarms, and a 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 can has a flip lid operable with a food pedal and is located in the kitchen area. Cleaning agents are kept in a locked cabinet in the laundry area. Please continue to 809-C, Pg 2.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022

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 3	FACILITY NUMBER: 425802110
	VISIT DATE: 03/09/2022

NARRATIVE

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Medications are kept in a locked centrally stored cabinet.
The backyard has a patio with potted plants and a garden area, outdoor furniture including tables, cushioned chairs and couches. There is a covered sitting area for outdoor visitation. The surface is paved with concrete. The recycling bin, green waste bin, and trash bins are standard bins with flip lids. A locked private staff room is located at the end of a hallway.
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 has six (6) private bedrooms for each resident. Each resident’s room has lights and night stand lamps to provide sufficient lighting.
Residents participate at will in activities such as attending day program(s), outdoor excursions to beach areas, parks, and neighborhood walks. Residents also participate in worship meetings, dining in local eateries, and shopping local retail businsses. Due to the COVID-19 pandemic, celebrations have been limited to small group gatherings to recognize special holidays, birthdays, and life milestones.
There are three (3) bathrooms in the residence all of which are available for residents’ use. The bathrooms have secure grab bars.
Staff records were reviewed. LPA noted 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 via email.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022

LIC809 (FAS) - (06/04)

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