425850231-7-7-2023-29-AS-BPHS-CTHLJ2-20230707084710

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425850231
Report Date: 07/05/2023
Date Signed: 07/07/2023 08:47:21 AM

Document Has Been Signed on 07/07/2023 08:47 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	CASA OMEGA		FACILITY NUMBER:	425850231
ADMINISTRATOR:	GORDON, CARRIE M		FACILITY TYPE:	740
ADDRESS:	815 CAMBRIA WAY		TELEPHONE:	(805) 967-2014
CITY:	SANTA BARBARA	STATE: CA	ZIP CODE:	93105
CAPACITY:	3	CENSUS: 0	DATE:	07/05/2023
TYPE OF VISIT:	Case Management - Licensee Initiated	UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Carrie Gordon, Administrator/Licensee (Not Present)		TIME COMPLETED:	05:00 PM

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On 07/05/2023, Licensing Program Analyst (LPA) Brian Phillips arrived unannounced to the facility to conduct a Case Management Facility Closure Visit, initiated by the Licensee.

Community Care Licensing (CCL) Goleta Office had previously received a mailed Forfeiture Information document detailing Certification of Non-Operation of the facility for the reason of No Longer Interested, signed and dated by Administrator Carrie Gordon on 06/12/2023. An incident report dated 06/11/2023 was included detailing that the only resident of the facility was moved to a Skilled Nursing Facility (SNF) on a permanent basis on 06/10/2023. As required by regulation, the original license was forfeited to CCL upon closure of the facility by Administrator Carrie Gordon on 06/12/2023.

This is a closure initiated by the Licensee. The licensee has chosen to surrender the facility license. A written notification of the Certification of Non-Operation has been signed and remitted, along with the original license, to the Regional Office (RO) of CCL Goleta. The license will be forfeited upon receipt of the signed Certification of Non-Operation or other written notification from the licensee indicating they are no longer in business. For this facility, the LPA arrived on 07/05/2023 to follow-up receipt of a surrendered license by conducting a case management inspection to verify that the facility is no longer in operation.

The facility is a one story four bedroom three bath facility, previously housing a single resident who has since been placed in a Skilled Nursing Facility (SNF) and is no longer at the facility. LPA conducted an observation of the front physical environment upon arrival to the facility. The front entry is a paved walkway with greenery and a front lawn. LPA noted no vehicles in the driveway of the facility, and an unclaimed mail parcel on the front entryway. LPA knocked multiple times and rang the doorbell, but there was no answer from within. LPA was able to observe from outside the facility that the entry way leads into an open room and kitchen, both of which appeared to be vacated. Continued on 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Brian Phillips	TELEPHONE: (805) 956-1636
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023

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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CASA OMEGA	FACILITY NUMBER: 425850231
	VISIT DATE: 07/05/2023

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From observations through facility windows, the LPA observed 4 bedrooms and 3 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. All of the bedrooms and bathrooms appeared to be vacated.

LPA observed a gate around the side of the facility and noticed that all outside electrical outlets had no plugs attached. The backyard itself appeared vacated. LPA was not able to observe the inside of the garage of the facility, but from the rest of the observations the physical environment was clean, in good condition, and appeared vacant. Walls, windows, ceilings, floors and floor coverings, and doors were checked.

Due to there being no individuals at the facility at the time of the Facility Closure inspection, report will be emailed to Administrator for signature. Signature on file

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Brian Phillips	TELEPHONE: (805) 956-1636
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023

LIC809 (FAS) - (06/04)

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