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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 02:02:42 PM


Document Has Been Signed on 12/30/2022 02:02 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:Post LicensingUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Steven Ronstadt, Administrator TIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual.

A post licensing was not conducted on/around May 2022. This report is being generated to document a post-licensing inspection.

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.

A separate 809 report was created to document the annual inspection.
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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