197610381-3-15-2023-31-AS-ERIS-CPXP3F-20230315105728

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610381
Report Date: 03/15/2023
Date Signed: 03/15/2023 10:57:41 AM

Document Has Been Signed on 03/15/2023 10:57 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	RAYWOOD VILLA INC		FACILITY NUMBER:	197610381
ADMINISTRATOR:	FONSECA, JASON		FACILITY TYPE:	740
ADDRESS:	42659 RAYWOOD DRIVE		TELEPHONE:	(562) 481-6306
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY:	6	CENSUS:	DATE:	03/15/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Jason Fonseca		TIME COMPLETED:	11:00 AM

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On 03/15/2023 at 9:00 a,m, Licensing Program Analyst (LPA) Evelin Rios conducted an announced pre-licensing visit to the location mentioned above. LPA met with applicant Jason Fonseca and Therese Fonseca. The applicant has obtained fire clearance for a total capacity of 6 of which 3 may be non-ambulatory and 3 may be bedridden. STD 850 states bedridden clients may occupy any of the rooms in the home.

LPA inspected facility for fire safety, personal accommodations, and food service. Smoke alarms are hardwired and were tested at 9:19 a.m. and functioning properly. LPA observed carbon monoxide detectors through out the facility. LPA observed three fire extinguishers, one in the kitchen area, one in the hallway and one in the garage to be fully charged. There are no firearms/ammunition stored on the property.

There are five bedrooms total. One bedroom is designated for double occupancy and four bedrooms are single occupancy. There is no staff room. Administrator stated there will be awake staff at night. Each bedroom features beds with appropriate bedding, chairs, night stands, closet space and appropriate lighting. There are three full bathrooms. Hot water in the bathroom was measured at 119.1 degrees Fahrenheit. Bathroom had nonskid shower mats and two out of the three bathroom were missing appropriate grab bars. All toilets had grab bars directly installed onto the toilet. LPA observed these to be sturdy. Extra linens and towels were observed in a closet located by the bedrooms. The facility has a room that is able to lock designated as an office where resident records and staff records will be stored.

Common areas include the living room and two dining areas that were clean, safe and appropriately furnished. The potential facility has personal rights, house rules, rights to resident council, emergency exit sketch, and emergency disaster plan posted in the entry and by one of the dinning areas.

Kitchen was observed to have appropriate utensils, pots and pans, dishes and drink ware. Sharps are kept in a locked kitchen cabinet. Chemicals and cleaning supplies are kept locked in a cabinet under the kitchen sink. (Continued LIC 809C)

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023

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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: RAYWOOD VILLA INC	FACILITY NUMBER: 197610381
	VISIT DATE: 03/15/2023

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The home features an attached garage with accessibility from inside the home. However, the garage door will remain locked at all time. There is a separate laundry entry to the garage where the washer and dryer are located. Detergents will be kept in locked cabinet under the bathroom sink adjust to the laundry room.

Medications will be stored in a closet that is able to lock located in a hallway by the bedrooms inaccessible to residents. LPA observed a first aid kit and emergency kit in the designated medication closet.

The backyard, completely fenced and gated, features a covered patio with chairs for resident use. There is also a self-latching gate on one side of the backyard for resident access. There is also a small pond measuring 130 inches by 64 inches. One side of the pond is inside the covered patio and has a cover that may lock and outside of the covered patio the pond is exposed with no cover and will connect to a running stream of water not measuring over 2 inches in depth.
Component III was conducted with the Licensee and Administrator both confirmed understanding of Title 22.

LPA requested the following photographic/copy proof from the applicant on or before 03/31/23:

Cover for exposed pond side or fence in exposed pond side.
Two shower grab bars
One bath tub grab bar
30 day emergency food supply

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

Exit interview conducted and report issued.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023

LIC809 (FAS) - (06/04)

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