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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610381
Report Date: 05/16/2024
Date Signed: 05/16/2024 12:11:09 PM


Document Has Been Signed on 05/16/2024 12:11 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:RAYWOOD VILLA INCFACILITY NUMBER:
197610381
ADMINISTRATOR:FONSECA, JASONFACILITY TYPE:
740
ADDRESS:42659 RAYWOOD DRIVETELEPHONE:
(562) 481-6306
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:6CENSUS: 0DATE:
05/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Therese Fonseca, LicenseeTIME COMPLETED:
12:40 PM
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At 10:25 AM Licensing Program Analyst (LPA), Huma Rahimi, conducted an unannounced annual inspection at the facility mentioned above. LPA met with the Licensee Therese Fonseca, and explained the reason for the visit. Physical tour was conducted with the Licensee and LPA observed the following:

Census: 0

Kitchen: At approximately, 10:55 AM LPA toured the kitchen area and observed enough supplies of staple non-perishable for minimum one (1) week and perishable for two (2) days at the facility. All knives and sharps observed to be locked in a the kitchen cabinet by the sink. All chemicals and toxins were locked in a cabinet under the sink. LPA observed three fire extinguishers, one in the kitchen area, one in the hallway and one in the garage to be fully charged.

Medications: At approximately, 10:59 AM LPA observed medications are centrally stored and locked in a closet in the hallway.

Bedrooms: The facility is fire cleared for six (6) non-ambulatory residents. LPA observed total of five (5) bedrooms designated for resident's use. There is no staff room. Bedroom # five (5) is shared and all other bedrooms are private. All bedrooms are properly furnished, clean and have appropriate bedding and linens. Facility has awake staff.

Bathrooms: LPA observed three (3) bathrooms and both appeared to be clean and in good repair. Properly supplied with toilet papers, soap and paper towels. LPA observed appropriate grab bar and resident's bathroom had non-skid mat. LPA observed appropriate hand washing signs posted in each bathroom. Hot water temperature measured at 113.9°F. Continue on LIC809-C

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma RahimiTELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2024
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: RAYWOOD VILLA INC
FACILITY NUMBER: 197610381
VISIT DATE: 05/16/2024
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Common Areas: The facility maintains a comfortable temperature at 76°F. The living room and dining area appeared clean and were properly furnished. The living room has a television, comfortable furniture. No obstructions and or tripping hazards throughout the facility.

Laundry Room: The laundry room is next to the bedroom # three (3) in the hallway. LPA observed the laundry room locked and inaccessible to residents. The laundry detergents are observed to be locked in the bathroom cabinet next to the laundry room. The garage is next to the laundry is currently used as a storage.

Smoke detectors/carbon monoxide. Smoke detectors were located throughout the facility, and at 11:10 AM they were tested and observed to be operational. Carbon monoxide was located in the kitchen and was also tested and observed to be operational.

Outside areas: At approximately, 10:15 AM LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. LPA observed a fish pond and inaccessible to residents. The fish pond was fenced and locked. There is no swimming pool.



The facility has no residents and staff; therefore, no record review for staff or residents completed on today's visit.

Administrative: LPA collected Certificate of Liability Insurance.

No deficiency cited during today’s visit.

Exit interview conducted and copy of this report signed and delivered.

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma RahimiTELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024
LIC809 (FAS) - (06/04)
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