<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002864
Report Date: 01/17/2024
Date Signed: 01/17/2024 02:41:34 PM


Document Has Been Signed on 01/17/2024 02:41 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 6DATE:
01/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Kelly Conley, House ManagerTIME COMPLETED:
02:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual. LPA met with Tammy Parrel, caregiver, and stated reason for the inspection. LPA spoke to the Administrator, Steven Ronstadt, who stated he or Kelly Conley, House Manager, would be at the facility shortly. Kelly arrived at approximately 10:45 am. LPA observed (1) resident to be in the common area watching television and (5) residents to be in their resident rooms. The facility is licensed for (6) non-ambulatory residents. There is a hospice waiver approved for (3) residents. Currently there are (0) residents on hospice.

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 and the bathrooms to have the necessary grab bars, non-skid flooring, paper towels and hand-washing posters. There is sufficient 2+day perishable and 7+day non-perishable supply of food, and locked sharps in the kitchen. Locked medications are in a separate closet nearby. LPA observed locked toxins in the garage and laundry area. The inside temperature measured 72*F, and hot water measured 120*F in the kitchen and resident bathroom. There are games/activities on site. The fire extinguisher was last serviced 5/17/23 and facility conducts quarterly emergency drills. There is sufficient incontinent/PPE products. RCFE Administrator Certificate #6051256740- exp 2/26/2025. All other required postings are posted. There are cameras in the common area and night-lights also.There is (1) unlocked gate from the inside back patio and no bodies of water or a pool. LPA reviewed (2) resident files and medications. Files were organized with current physician reports and care plans. Medication orders matched medication being administered. LPA reviewed (3) staff files. Files were organized and contained required documentation. Staff training is not current within the last (12) months. All staff is fingerprint cleared and associated. Administrator to email a copy of an updated copy of LIC500, LIC308 and the current liability insurance by 1/24/24. There are (2) deficiencies issued during today's inspection on the 809D pages. Exit interview. Copy of report and appeal rights provided provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 01/17/2024 02:41 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: OLD RANCH VILLA
FACILITY NUMBER: 345002864

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2024

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 in (3) out of (5) staff which poses/posed a potential health, safety or personal rights risk to persons in care.

Record review shows CPR/First Aid certifications expired in April 2023.
POC Due Date: 01/31/2024
Plan of Correction
1
2
3
4
Licensee/Administrator agrees to request staff renew their CPR/First Aid Certifications by 1/24/24. Documentation to be provided to LPA by 1/31/24 or when completed.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

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 in (3) out of (3) staff records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2024
Plan of Correction
1
2
3
4
Licensee/Co-Administrator agrees to complete staff training records ensuring (20) hours has been completed within the last (12) months for each staff (S1, S2 and S3). Licensee will consider subscribing to an approved-online training program for required trainings. Documentation to be provided to LPA that each staff has completed (20) hours of required annual training.
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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2