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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002864
Report Date: 12/30/2022
Date Signed: 12/30/2022 01:57:43 PM


Document Has Been Signed on 12/30/2022 01:57 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:OLD RANCH VILLAFACILITY NUMBER:
345002864
ADMINISTRATOR:RONSTADT, STEVENFACILITY TYPE:
740
ADDRESS:8312 BLAYDAN CTTELEPHONE:
(831) 706-8481
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:6CENSUS: 4DATE:
12/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Steven Ronstadt, Administrator TIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual.
LPA met Norma Green and Joan Wisdom, caregivers, who contacted Administrator, Steven Ronstadt, by phone. Administrator and House Manager, Kelly Conley, arrived at approximately 12:15 pm. LPA observed (2) residents in the common area and (2) residents in their rooms at the start of the inspection. The facility is licensed for (6) non-ambulatory residents and has a hospice waiver for (4).An increase was approved on 5/16/22. Currently, there is (0) residents on hospice. Prior to initiating today's inspection, LPA completed required COVID-19 Department protocols, wore a surgical mask and was screened per Covid-19 precautionary measures upon entering the facility.

LPA and House Manager toured the interior and exterior of the facility including the common areas, (6) resident bedrooms, (4) resident full bathrooms and (1) resident/staff bathroom, kitchen, laundry area and garage. All but (1) resident room has an exit door to the outside. LPA observed the facility to be clean, in good repair and odor-free. LPA observed the bathrooms to have the necessary grab bars, non-skid flooring, paper towels and hand-washing posters. LPA observed sufficient 2+day perishable and 7+day non-perishable supply of food, and locked sharps in the kitchen and locked medications in a separate closet. LPA observed locked toxins in the garage. LPA observed the inside temperature to be 73*F. LPA observed games/activities on site. Discussed vaccination status of residents/staff and eligibility for boosters. LPA observed multiple Covid posters throughout as well as other required postings. LPA observed (1) unlocked gate from the inside back patio. There are no bodies of water or a pool. LPA observed sufficient incontinent and PPE products on hand. RCFE Administrator Certificate #6051256740- exp 2/26/2023. Facility conducts fire drills quarterly. Fire extinguisher was last serviced on 4/29/22.

Administrator to email a copy of an updated copy of the LIC500, and the current liability insurance by 1/7/23. There are no deficiencies issued during today's inspection.

Exit interview. Copy of report provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 12/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/30/2022
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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