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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306006164
Report Date:
06/07/2022
Date Signed:
06/07/2022 09:43:19 AM
Document Has Been Signed on
06/07/2022 09:43 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
,
770 THE CITY DR., SUITE 7100
ORANGE
,
CA
92868
FACILITY NAME:
RUBY COTTAGE
FACILITY NUMBER:
306006164
ADMINISTRATOR:
BRAVO, VENUS S
FACILITY TYPE:
740
ADDRESS:
24182 MCCOY RD
TELEPHONE:
(949) 583-1996
CITY:
LAKE FOREST
STATE:
CA
ZIP CODE:
92630
CAPACITY:
6
CENSUS:
5
DATE:
06/07/2022
TYPE OF VISIT:
Prelicensing
ANNOUNCED
TIME BEGAN:
09:12 AM
MET WITH:
Arnold Bravo - Administrator
TIME COMPLETED:
09:50 AM
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Licensing Program Analyst (LPA) Patricia Velazquez conducted an announced visit to Ruby Cottage. LPA Velazquez was allowed entry into the facility and met with Administrator Arnold Bravo. The purpose of today's subsequent Pre-Licensing visit was to follow-up on the issues that were present during the initial Pre-Licensing visit dated 05/19/2022. The following issues were observed and required correction:
Repair or replace the cracked tile in the shower of a resident bathroom
Repair the shower door handle in a resident bathroom and ensure the door closes properly
Obtain the Complaint Poster and post in the entry area of the facility
Relocate the Ombudsman poster to the entry area of the facility
Obtain a First-Aid manual
Clean and remove grease stains in both ovens
Post handwashing instructions in each resident bathroom
Add Cough Etiquette posters throughout the facility
Obtain 2 more chairs for outdoor seating for residents
Remove the rusted bench from the side yard
Check the faucet in a resident bathroom that was spraying water in different directions onto the countertop
On today's visit the aforementioned items have been addressed and corrected. The items reviewed during this visit are in compliance. The Pre-Licensing is now complete. The license will be granted upon completion of a final review and approval from the Licensing Program Manager and the Central Applications Bureau. An exit interview was conducted with Administrator Arnold Bravo and a copy of this report was provided at the time of this visit.
SUPERVISOR'S NAME:
Sheila Santos
TELEPHONE:
(713) 334-2062
LICENSING EVALUATOR NAME:
Patricia Velazquez
TELEPHONE:
(949) 236-0556
LICENSING EVALUATOR SIGNATURE:
DATE:
06/07/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/07/2022
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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