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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366413255
Report Date: 12/05/2023
Date Signed: 12/05/2023 01:06:32 PM


Document Has Been Signed on 12/05/2023 01:06 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507



FACILITY NAME:RANCH COUNTRY HOMEFACILITY NUMBER:
366413255
ADMINISTRATOR:MELROSE RAMOSFACILITY TYPE:
740
ADDRESS:4189 LEXINGTON AVETELEPHONE:
(909) 628-6999
CITY:CHINOSTATE: CAZIP CODE:
91710
CAPACITY:6CENSUS: 5DATE:
12/05/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:07 PM
MET WITH:Staff Anita Tablit and Tita MateoTIME COMPLETED:
01:15 PM
NARRATIVE
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On this date of inspection, relating to complaint #56-AS-20231204101736, LPA Prieto toured the facility with staff Anita Tablit and observed two (2) deficiencies not related to the above complaint number. During inspection of facility kitchen, LPA Prieto did observe a can of roach spray stored in drawer under the kitchen sink that was not locked.

Moreover, during time of inspection, LPA Prieto attempted to communicate with the facility Administrator Melrose Ramos, but was not available reach MS Ramos in person or by phone. No staff at the facility, during this inspection, were designated to represent the administrator during Ms Ramos absence.

LPA Prieto informed staff Tablit that deficiencies will be issued as this poses potential health, and safety risk to residents in care.

An exit interview was conducted where this report LIC809, LIC809D and Appeal Rights were discussed and provided to Ms Tablit.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2023
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 12/05/2023 01:06 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: RANCH COUNTRY HOME
FACILITY NUMBER: 366413255

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/22/2023
Section Cited
CCR
87405(a)

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Administrator - Qualifications and Duties
All facilities shall have a certified administrator with enough freedom from other responsibilities and a sufficient number of hours on the premises to give adequate attention to the administration of the facility. This requirement is not met as evidenced by:
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Administrator Ramos to submit documentation of designated administrator during her absence to be able address matters at her facility when she cannot attend during LPA visits, by POC date.
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Administrator Melrose Ramos was not available during time of inspection and was not able to communicated with by phone.
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Type B
12/05/2023
Section Cited
CCR87705(f)(2)

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Care of Residents with Dementia
The following shall be stored inaccessible to residents with dementia:
toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement was not met has evidenced by:
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Staff removed toxin, during today's inspection, and placed in cabinet in the laundry room, which is locked and inaccessible to clients.
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During time of facility kitchen inspection, LPA observed a can of roach spray, under the kitchen sink which was unlocked and accessible to clients.
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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: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2