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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425802110
Report Date: 03/06/2024
Date Signed: 03/06/2024 02:08:51 PM


Document Has Been Signed on 03/06/2024 02:08 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 3FACILITY NUMBER:
425802110
ADMINISTRATOR:NORMA DEMONTEVERDEFACILITY TYPE:
740
ADDRESS:126 SANTA ANA AVENUETELEPHONE:
(805) 683-0980
CITY:SANTA BARBARASTATE: CAZIP CODE:
93111
CAPACITY:6CENSUS: 5DATE:
03/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Rhoda Demonteverde, Co-Administrator & Melissa Batista, Quality Control ManagerTIME COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced required Annual Inspection at the above named facility. Upon arrival, LPA was greeted by Staff 1 (S1) and LPA explained the purpose of the visit. At the time of arrival, there were two (2) staff on duty. There are currently five (5) residents residing in the facility. Four (4) residents were present and one (1) resident was attending an adult day program. LPA informed staff of the visit. Rhoda Demonteverde, Co-Administrator and Melissa Batista, Quality Care Manager arrived at approximately 12:00 pm. Norman Demonteverde, Co-Administrator arrived at the facility at approximately 1:00 pm.
Entrance interview conducted.
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. The facility is home to 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 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.
Medications are kept in a locked centrally stored cabinet and administered as prescribed.
Please continue to 809-C, Pg 2.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2024
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: 03/06/2024
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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 nightstand lamps to provide sufficient lighting.
Residents participate at will in activities such as reminiscent activities, movie nights, attending day program(s), outdoor excursions including scenic rides to beach areas, parks, and neighborhood walks. Residents also participate in special celebrations, worship meetings, dining in local eateries, and shopping at local retail businesses.
There are three (3) bathrooms in the residence all of which are available for residents’ use. The bathrooms have secure grab bars.
Residents’ records were reviewed for Admission Agreements, Pre-Appraisals, Appraisals, health screenings, and administration of medications.

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

DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024
LIC809 (FAS) - (06/04)
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