425802112-3-9-2022-29-AS-KKOS-CCD2U8-20220309164155

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425802112
Report Date: 03/09/2022
Date Signed: 03/09/2022 04:42:38 PM

Document Has Been Signed on 03/09/2022 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 4		FACILITY NUMBER:	425802112
ADMINISTRATOR:	DEMONTEVERDE, NORMAN RHODE		FACILITY TYPE:	740
ADDRESS:	112 SANTA ANA AVENUE		TELEPHONE:	(805) 967-1461
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:	02:20 PM
MET WITH:	Rhoda Demonteverde, Director of Care, and Norman Demonteverde, Co-Administrator		TIME COMPLETED:	03:30 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. LPA arrived at 2:20 pm and was greeted by Staff 1 (S1). LPA explained the purpose of the visit. At the time of arrival, there were two (2) staff on duty and six (6) residents present. LPA informed staff of the visit. Rhoda Demonteverde, Director of Care arrived at the facility at 2:20 pm. Norman Demonteverde, Co-Administrator arrived at 2:25 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. 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 conducted on 2/14/2022. LPA observed one (1) carbon monoxide alarm, ten (10) smoke alarms, and one (1) 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 is kept in a cabinet under the kitchen sink. 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)

Page: 1 of 2

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 4	FACILITY NUMBER: 425802112
	VISIT DATE: 03/09/2022

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
26
27
28
29
30
31
32

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 and cushioned chairs. 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 temperature. Hallways, bedroom doors, and walls are in good repair.
The facility has six (6) private bedrooms for six (6) residents. Each resident’s room has lights and night stand lamps to provide sufficient lighting.
There are three (3) bathrooms in the residence all of which are available for residents’ use. The bathrooms have secure grab bars.
Residents participate at will in activities such as neighborhood walks, outdoor excursions to beaches and parks, local eateries, retail shopping, special events, live theater, movies, and worship meetings. Special celebrations and life milestones are celebrated in small gatherings due to the COVID-19 pandemic.
Staff records were reviewed. LPA noted that 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)

Page: 2 of 2