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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850231
Report Date: 01/21/2022
Date Signed: 01/21/2022 03:28:55 PM

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:CASA OMEGAFACILITY NUMBER:
425850231
ADMINISTRATOR:GORDON, CARRIE MFACILITY TYPE:
740
ADDRESS:815 CAMBRIA WAYTELEPHONE:
(805) 967-2014
CITY:SANTA BARBARASTATE: CAZIP CODE:
93105
CAPACITY:3CENSUS: 0DATE:
01/21/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Carrie Gordon, AdministratorTIME COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA) Kristin Kontilis conducted an announced pre-licensing visit to the facility. LPA met with Administrator Carrie Gordon and Norman Gordon, Director of Operations. LPA arrived at approximately 11:20 am.

Entrance Interview Conducted:
This is a one-story four-bedroom three-bath facility. The facility will be home to male residents with developmental disability diagnoses. A tour of the physical environment was conducted. The front entry is a paved walkway with greenery and a front lawn. The entry way leads into an open dining room, living room, and kitchen.
The kitchen is open style with an island for food preparation and cabinets surrounding the area the kitchen area. There is a refrigerator, microwave, and an oven and stove. There is an ample amount of cabinets for food and appliance storage, including an appliance garage with a toaster and panini griddle.
A locked medication cabinet is located in a cabinet between the dining area and kitchen. It contains a first aid kit and medications for residents. The medications will be inaccessible to residents in care.
There are four bedrooms and three bathrooms. Bedroom #1 is a private bedroom with a private bathroom. Bedrooms #2 and #3 are private bedrooms with a shared bathroom off the hallway between Bedrooms #2 and #3.
The backyard consists of a variety of fruit trees, a patio area, a large portable umbrella, chase lounges, a putting green area, paved walkways, and planted garden areas. A garage is located on the west side of the facility which consists of washer and dryer, storage cabinets, first aid kit, fire extinguisher, and emergency supplies. Toxic substances and cleaning supplies are kept in a locked cabinet in the garage.
There are three fire extinguishers inside the facility, two fire extinguishers located in the outdoor area, and one fire extinguisher in the facility vehicle. The fire extinguishers were serviced on January 6, 2022.
LPA observed the required posting of the complaint poster, bill of rights and Resident’s Rights. LPA inspected the facility for fire safety, personal accommodations, and food service.

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

DATE: 01/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2022
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: CASA OMEGA
FACILITY NUMBER: 425850231
VISIT DATE: 01/21/2022
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The facility has four (4) combination smoke detectors and carbon monoxide alarms and eight (8) smoke detectors all in good working order.
A tankless on-demand water heater provides automatic heated water throughout the facility at a pre-set temperature. Water temperature was measured at 119 degrees Fahrenheit (F) at 1:01 pm.
The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked.
LPA determined that the facility has met licensing requirements per Title 22 California Code of Regulations.

Due to technical issues, report will be emailed to Administrator for signature.

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

DATE: 01/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2022
LIC809 (FAS) - (06/04)
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