366402735-1-19-2022-18-AS-RLAA-CAU3AN-20220119170501

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366402735
Report Date: 01/19/2022
Date Signed: 01/19/2022 05:05:16 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	RAMADA RANCH		FACILITY NUMBER:	366402735
ADMINISTRATOR:	EMERSON, DIANE L.		FACILITY TYPE:	740
ADDRESS:	35859 RAMADA LANE		TELEPHONE:	(909) 797-7822
CITY:	YUCAIPA	STATE: CA	ZIP CODE:	92399
CAPACITY:	6	CENSUS: 3	DATE:	01/19/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Veda Garcia and Maritza White		TIME COMPLETED:	05:15 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 Analysts (LPAs) Melody Brown and Rohit Lama made an unannounced visit to the facility to conduct an annual inspection, with emphasis on infection control. LPA was greeted and granted entrance by caregiver Veda Garcia and LPAs explained the purpose of today's visit. Administrator was contacted and informed of LPAs arrival. Caregiver Maritza White arrived for the PM Shift while LPAs were at the facility. Caregiver Veda Garcia accompanied LPAs Brown and Lama on a tour of the inside and outside of the facility. During today’s visit, LPAs made observation pertaining to the facility’s current infection control measures. LPAs observed a screening area, proper signages throughout the facility, sufficient hand hygiene supplies, cleaning supplies, and a sufficient supply of Personal Protective Equipment (PPE). The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, cleaning and disinfection are in adequate quantities, and that staff are trained in overall infection control. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and resident for COVID-19, when and how to isolate/quarantine resident, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas/surfaces. The facility also has a plan in place to monitor resident regularly for any changes in condition and to subsequently notify the resident’s physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses. LPAs Brown and Lama reviewed the facility’s Covid-19 training for facility staff and confirmed that staff have been trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing of PPE. LPAs inquired as to if staff have been fit tested for N95 masks and Care Giver reported to LPAs that at this time staff have not been fit tested. *Continuation on LIC 809-C*

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Rohit Lama	TELEPHONE: (951) 217-9826
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: RAMADA RANCH	FACILITY NUMBER: 366402735
	VISIT DATE: 01/19/2022

NARRATIVE

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***Continuation from LIC 809***

LPAs will be issuing a Technical Assistance Advisory Note during today's inspection for staff not being fit tested for N95 masks. LPAs will not be issuing a deficiency for this item due to the facility not currently having any COVID-19 positive residents, and N95 masks only needing to be worn when a resident is COVID-19 positive or under observation while awaiting test results.

Additionally, all residents and staff have been vaccinated and are practicing other COVID-19 precautions, which minimize the risk of them contracting COVID-19. LPAs will be providing caregivers with the information for Provider Information Notice (PIN) PIN-21-10-ASC which contains resources for getting staff fit tested for N95 masks.

In addition, during the tour LPAs noticed that one of the bathrooms (located inside one of the vacant rooms) have evidence of water damage (walls have water damage and parts of the dry wall were broken). There were additional signs of water damage in the dining area window. The carpeted floor of the dining area also had water stains. Also, LPAs observed that the cupboards in the Laundry Room are also in disrepair. LPAs will be issuing a deficiency for this because this poses a potential health and safety risk to residents in care.

Moreover, during the tour, LPAs noticed that the screen for the dining area window was in disrepair and needs to be addressed. LPAs will be issuing a technical violation for this issue.

An exit interview was conducted with Maritza White and a copy of this report (LIC809), LIC 809-D, LIC9102-TV, LIC 9102-TA, and Appeal Rights were provided.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Rohit Lama	TELEPHONE: (951) 217-9826
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2022

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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: RAMADA RANCH	FACILITY NUMBER: 366402735
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interviews, the licensee did not comply with the section cited above because the toilet, bathroom walls, window sill, and drawers (in laundry room) are in disrepair, which poses a potential health, safety risk to persons in care.
	POC Due Date: 01/26/2022
	Plan of Correction
1 2 3 4	Submit proof of repairs - invoices, work orders, pictures that water leak(s) have been addressed to LPA by POC due date. The same proof shall be provided

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: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Rohit Lama	TELEPHONE: (951) 217-9826
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2022

LIC809 (FAS) - (06/04)

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