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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608564
Report Date: 05/04/2022
Date Signed: 05/04/2022 11:36:25 AM

Document Has Been Signed on 05/04/2022 11:36 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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:RBG RESIDENTIAL HOMEFACILITY NUMBER:
197608564
ADMINISTRATOR:BETTY GONZALEZFACILITY TYPE:
735
ADDRESS:5052 RAINER AVENUETELEPHONE:
(661) 480-7803
CITY:PALMDALESTATE: CAZIP CODE:
93552
CAPACITY: 4CENSUS: 2DATE:
05/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Betty Gonzalez, Administrator TIME COMPLETED:
11:55 AM
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At 10:00am Licensing Program Analyst (LPA), Angela Panushkina, conducted an unannounced annual inspection at the facility mentioned above. LPA was greeted by the Administrator who granted access to the facility. Reason for the visit was explained.

LPA conducted physical tour with the Administrator and observed the following:

Infection control: LPA reviewed the facility mitigation plan (approved on 05/06/2021) to make sure licensee was following current infection control recommendations. Upon arrival, LPA was screened and asked to sign-in the visitors’ log. In addition, LPA was asked all infection control questions. Proper signage was observed inside along the hallway and in the restrooms. Hand sanitizer was also observed. Administrator stated they have sufficient PPE supplies for clients and staff. LPA observed all trash can throughout the facility have fitted lids.

Kitchen: At 10:15am LPA toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. The fire extinguisher was last serviced on 03/11/2022.



Medications: At 10:20:am LPA observed medications are centrally stored and locked in a cabinet along with all knives and sharps and inaccessible to clients in care.

Common Areas: The facility maintains a comfortable temperature at 73°F. The living room and dining area were properly furnished. Laundry room is located on a second floor and kept locked and inaccessible to clients in care. No obstructions and or tripping hazards throughout the facility.
Continue on LIC809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE: DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2022
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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: RBG RESIDENTIAL HOME
FACILITY NUMBER: 197608564
VISIT DATE: 05/04/2022
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Bedrooms: There are four (4) bedrooms designated for clients use and have sufficient lighting. All bedrooms are properly furnished, clean and have appropriate bedding and linens.

Bathrooms: At 10:25am LPA observed all bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. The hot water temperature measured at 105°F. LPA observed appropriate hand washing signs posted in each bathroom.



Smoke detectors/carbon monoxide. Dual smoke and carbon monoxide detectors were located throughout the facility, and at 10:30am they were tested and observed to be operational.

The garage: LPA observed extra PPE supplies and food storage in an attached garage and kept locked and inaccessible to clients in care.



Outside areas: At 10:45am LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. LPA discussed the importance of maintaining the care and supervision to meet the needs of clients. There are no bodies of water.

Administrative: LPA collected Certificate of Liability Insurance and LIC500.

No citations issued during this visit. Exit interview conducted. Copy of report emailed to Licensee.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022
LIC809 (FAS) - (06/04)
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