197608564-1-3-2024-31-AS-TSMH-CYR23F-20231221160217

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608564
Report Date: 12/21/2023
Date Signed: 01/03/2024 07:59:27 AM

Document Has Been Signed on 01/03/2024 07:59 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 HOME		FACILITY NUMBER:	197608564
ADMINISTRATOR:	BETTY GONZALEZ		FACILITY TYPE:	735
ADDRESS:	5052 RAINER AVENUE		TELEPHONE:	(661) 480-7803
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93552
CAPACITY: 4		CENSUS: 3	DATE:	12/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:			TIME COMPLETED:	04:05 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), Tihesha Smith conducted an unannounced Required 1-year inspection at this facility LPA knocked on door and waited approximately 30 minutes before staff came to front door.LPA disclosed to staff the purpose of the visit. LPA conducted a tour of the physical plant at approximately 11:20 am to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. Common areas were observed for the ability to safely serve the needs residents. These included the living room, dining room, family room and kitchen. The common areas were checked for cleanliness and furniture was checked for functionality. Common areas observed to have adequate seating for residents, however areas required cleaning. Dinning room table filled with office paperwork and trash. Facility has foul odor. LPA reviewed the food service areas, food storage and supply (perishable and nonperishable foods). The kitchen food supply was observed and sufficient for the three (3) residents currently residing there. Two (2) days of perishable food observed. The freezer is stocked with meats and frozen vegetables. Pantry filled with canned goods and cluttered with administrator personal items. Resident medications, sharps and first aid supplies stored in roller cabinet drawers near sliding door in kitchen Medications and sharps observed to be locked and inaccessible to residents in care. There are two (2) fire extinguishers on in kitchen and one upstairs attached to wall. Fire extinguisher observed to be charged and replacement fire extinguishers on hand. Laundry room is located upstairs next to bathroom. The appliances observed to be in functional.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: RBG RESIDENTIAL HOME	FACILITY NUMBER: 197608564
	VISIT DATE: 12/21/2023

NARRATIVE

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(Cont from 809)

The facility has a total of six (6) bedrooms and (3) bathrooms. There are two (2) staff rooms in the facility. During this visit: One (1) room downstairs used for resident private room. Five bedrooms upstairs used as follows:
Three (3) rooms for residents: with the administrator occupying empty room designated for residents. The remaining two (2) rooms are used as staff/child room for a total of three (3) rooms used for staff and three (3) rooms for residents.

Three are three (3) bathrooms in the facility: two (2) for residents use.

The resident bedrooms were properly furnished with at least one chair or chairs available if need, nightstand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPA advised staff to ensure dirty utensils/dishes in residents’ rooms are removed and floors free of trash.

Each bathroom has posted “wash your hands” signs and the following items available: hand soap,
and trash cans. The hot water temperature was measured for the two (2) bathrooms to ensure it is
within the required range for residents’ comfort and safety. The water temperature range was between 105.8 and 109.4-degrees Fahrenheit.

Attached Garage used for: freezer storage, toxin storage and cluttered with administrator/family personal items (need to be removed). Garage observed to be locked and inaccessible. Backyard has the following: tables and chairs and covered areas. Locked shed.

Grounds: Piles of equipment, furniture, large basketball stand game on ground in front yard and trash will need to be removed.

Due to time constraints the annual will be completed at a later time

Exit interview conducted/copy of report given.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

LIC809 (FAS) - (06/04)

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