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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608564
Report Date: 03/06/2025
Date Signed: 03/06/2025 01:40:26 PM

Document Has Been Signed on 03/06/2025 01:40 PM - 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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:RBG RESIDENTIAL HOMEFACILITY NUMBER:
197608564
ADMINISTRATOR/
DIRECTOR:		BETTY GONZALEZFACILITY TYPE:
735
ADDRESS:5052 RAINER AVENUETELEPHONE:
(661) 480-7803
CITY:PALMDALESTATE: CAZIP CODE:
93552
CAPACITY: 4CENSUS: 3DATE:
03/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Betty Gonzalez-AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On 3/06/2025 at approximately 09:40 AM, Licensing Program Analyst (LPA), Angelica Segovia conducted an unannounced annual visit to the facility. LPA was greeted by the Administrator Betty Gonzalez and LPA stated the reason for their visit.

LPA asked for the census and Staff/Client Roster. LPA conducted a physical plant tour at approximately 11:00 AM and the following was noted:

The facility is a two-story building with six (6) bedrooms and three (3) bathrooms currently occupying three (3) clients. One (1) client room and one (1) bathroom are located downstairs. The remainder of the bedrooms and bathrooms are located upstairs. There are two (2) designated staff rooms, with one (1) private bathroom. The facility has an approved fire clearance for four (4) ambulatory clients. The facility is vendor through North Los Angeles Regional Center (NLARC) and is being operated at a Level II Adult Residential Home. Sign in sheet, hand sanitizer, gloves and masks are available.

Common areas: The living rooms and dining room were observed to be neat, clean, and organized. The rooms were observed to be properly furnished and in good repair. The facility maintains a comfortable temperature at 65°F. LPA observed a fire extinguisher to be located near the kitchen and dated 01/12/25. LPA observed required postings such as See/Say Something, Facility License, and Personal Rights alongside the kitchen area. A fireplace was observed to be covered and inaccessible to clients. A working telephone was observed.

Kitchen: The kitchen was observed to be clean and free from pests. Sufficient supplies of seven (7) day nonperishable foods and two (2) day perishable foods were observed. LPA observed an additional freezer used to store extra food located inside the garage. Knives, sharps, and medications were observed to be kept in a locked rolling cart located near the kitchen. Kitchen appliances were observed to be working and in proper condition. (continued on LIC 809-C)

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2025
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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: RBG RESIDENTIAL HOME
FACILITY NUMBER: 197608564
VISIT DATE: 03/06/2025
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Bedrooms: The clients’ rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are lighted appropriately. Extra linens/covers were observed stored in a storage cabinet located upstairs.

Bathrooms: The bathrooms were checked for cleanliness and proper operation. The hot water temperature was measured within regulations at 111.9 °F.

Garage: The garage can be accessed from inside of the facility and was observed to be kept locked. LPA observed cleaning solutions, toxins, and an extra freezer for food all stored within the garage and inaccessible to clients. Laundry Room: The laundry room is located upstairs near the bedrooms. LPA observed laundry room to be kept locked and cleaning solutions properly stored within laundry room and inaccessible to clients. Laundry appliances observed to be working and in proper condition.

Staff Room: LPA observed staff rooms locked and inaccessible to clients.

Backyard: The backyard of the facility is equipped with a designated shaded area with outdoor furniture for clients. LPA observed a locked storage unit. There is no body of water located at the facility.

Medications: Medications were observed stored in a locked rolling cart located downstairs. First-aid kit observed to be equipped with but not limited to bandages, scissors, digital thermometer, tweezer, and First Aid manual.

Smoke detectors and carbon monoxide observed to be working properly and were tested. The Last Fire Drill was conducted on 1/06/25.

Clients/Staff Records: LPA conducted a complete file review of client records. Client records appeared to be complete and updated. Staff records: LPA conducted a complete file review of staff records. Staff records appeared to be complete and updated.

There were no immediate health and safety hazard observed during the day of inspection. Exit interview conducted and a copy of this report was provided to the Administrator.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025
LIC809 (FAS) - (06/04)
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