425850279-11-9-2023-29-AS-KKOS-CXEPMP-20231109102636

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425850279
Report Date: 11/08/2023
Date Signed: 11/09/2023 10:26:44 AM

Document Has Been Signed on 11/09/2023 10:26 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	A CASA RHODA 1		FACILITY NUMBER:	425850279
ADMINISTRATOR:	DEMONTEVERDE, RHODA B.		FACILITY TYPE:	740
ADDRESS:	341 SANTA ROSALIA WAY		TELEPHONE:	(805) 679-5208
CITY:	SANTA BARBARA	STATE: CA	ZIP CODE:	93111
CAPACITY:	6	CENSUS: 4	DATE:	11/08/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:55 AM
MET WITH:	Rhoda Demonteverde, 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 required Annual Inspection to the facility. LPA met with Joyce Demonteverde, Co-Administrator and Norman Demonteverde, Co-Administrator. Rhoda Demonteverde, Co-Administrator arrived at approximately 1:15 pm. The facility is a one-story Residential Care Facility for the Elderly (RCFE). Currently, there are four (4) residents residing in the facility. The facility has a fire clearance for six (6) non-ambulatory residents, one (1) of which can be bedridden (Bedroom #5); and a hospice waiver for four (4) residents. Entrance nterview Conducted: At the time of arrival, there were two administrators and one caregiver on duty and four residents in care. The facility consists of a living room, dining area, kitchen, four private bedrooms, one shared bedroom, one private staff room, two full bathrooms with hallway access, and front and backyards. There are no bodies of water. Upon entrance of the residence, there is a walkway leading to the front door, garden areas, and a small sitting area. The entrance into the residence leads into the living and dining area. The kitchen consists of a refrigerator, dishwasher, microwave, sink, stove and oven, and a trash can with a flip lid. Sharps and medications are kept in locked kitchen cabinets and are inaccessible to residents in care. Emergency food is kept in a locked container in the dining area. The living room and dining area are furnished with adequate furnishings to sustain a capacity of six residents. There are two shared bathrooms off the hallway with access to all residents. Bathrooms have grab bars and non-skid flooring and mats. The facility maintains a comfortable room temperature. Residents’ records, personnel documents and records of confidentiality are kept in a locked file located in the dining 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: 11/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: A CASA RHODA 1	FACILITY NUMBER: 425850279
	VISIT DATE: 11/08/2023

NARRATIVE

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Residents may participate at will in various activities based on their individual interests and preferences. Residents participate at will in excursions to local eateries, special appointments, neighborhood walks, scenic drives, personal care appointments, community gatherings at the sister facilities within the area, special family recognition activities, and holiday celebrations.
The backyard consists of walkways, garden areas, sitting areas, covered patio, and a locked storage unit.
Recycling, green waste, and trash bins are standardized bins with flip lids. Each side of the residence has an unlocked entrance/exit gate.
There are two carbon monoxide detectors, ten (10) smoke alarms, and one hard wired pull alarm that alerts the local fire department. A First Aid kit is kept in the locked cabinet in the dining room.
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 and personal accommodations. First aid kit was observed to be complete.
The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, doors, floors and floor coverings were checked. The facility was seen to be in good repair inside and outside. Fire inspection was conducted on 2/6/2023 and 10/16/2023.

Exit interview conducted. No deficiencies noted. Copy of report issued at the time of the visit.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023

LIC809 (FAS) - (06/04)

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