306006164-7-25-2024-22-AS-ARJR-D7HRF5-20240725125834

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006164
Report Date: 07/25/2024
Date Signed: 07/25/2024 12:58:40 PM

Document Has Been Signed on 07/25/2024 12:58 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
ORANGE COUNTY RO, 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: 6	DATE:	07/25/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:56 AM
MET WITH:	Anaheizel Balonda-Caregiver, Venus Bravo-Administrator		TIME COMPLETED:	01:13 PM

NARRATIVE

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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit for the Required 1 Year Inspection. LPA explained the purpose of today’s visit, and was greeted and granted entry by Caregiver Anaheizel Balonda. Administrator (AD) Venus Bravo arrived shortly after.

For today’s visit, LPA observed a total of six residents in care and two staff members on duty.

LPA observed the Administrator's Certificate for facility AD Venus Bravo which expires on August 04, 2024.

LPA Ramirez toured the interior and exterior portions of the facility with AD Bravo. The facility is a single level structure and is licensed for six non-ambulatory residents, of which six may be on hospice and zero bedridden. There are a total of five bedrooms of which four are for residents and one for staff. LPA Ramirez toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. There are a total of four restrooms. Restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature tested between 105.3-106.2 degrees Fahrenheit.

Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to residents in care. Fire extinguisher was mounted, charged and located by the dining room.

During today's visit LPA observed as residents participated in singing while listening to the guitar being played.

CONTINUED ON LIC809-C..

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.	TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024

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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: RUBY COTTAGE	FACILITY NUMBER: 306006164
	VISIT DATE: 07/25/2024

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LPA Ramirez observed the emergency disaster and evacuation plan, which is located by main entrance. Facility had back-up emergency food and water supply. LPA observed that First Aid Kit had all the required components. LPA observed that medications and toxins were locked and inaccessible to residents in care.

For the exterior portion, LPA Ramirez observed a shaded area, patio furniture, and the grounds were free of any hazards. There is one gate in the backyard, which is self-closing and self-latching. No bodies of water were observed.

LPA reviewed five resident files and two staff files. LPA interviewed residents and staff present.

For today's visit one deficiency was issued per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with AD Bravo.

A copy of this report was provided at the time of exit.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.	TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/25/2024 12:58 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: RUBY COTTAGE	FACILITY NUMBER: 306006164
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. LPA observed that the staff CPR training and first aid trainings were expired.
	POC Due Date: 08/01/2024
	Plan of Correction
1 2 3 4	Licensee to email valid staff CPR and first aid training certificates by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.	TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024

LIC809 (FAS) - (06/04)

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