392700915-11-17-2023-27-AS-CYAG-CXNNGK-20231117092716

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700915
Report Date: 11/15/2023
Date Signed: 11/17/2023 09:27:32 AM

Document Has Been Signed on 11/17/2023 09:27 AM - 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	ROBUST CARE HOME, LLC		FACILITY NUMBER:	392700915
ADMINISTRATOR:	UBALDO, YASHMIN		FACILITY TYPE:	740
ADDRESS:	1627 MERIDIAN STREET		TELEPHONE:	(650) 653-1608
CITY:	MANTECA	STATE: CA	ZIP CODE:	95337
CAPACITY:	4	CENSUS: 4	DATE:	11/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Yashmin Ubaldo		TIME COMPLETED:	01:00 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	Unannounced annual visit made out to this facility on 11/15/2023 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Yashmin Ubaldo, at this time. A brief interview was conducted with the facility designated Administrator at this time. It was learned that this facility was also vendorized through Valley Mountain Regional Center (VMRC) to be able to accept and retain up to (4) Level 4I residents at any given time. Current census was 4 residents. There were no residents under the care of hospice or home health at this time according to statements made by the facility designated Administrator. Tour of this facility was conducted. A tour of the facility kitchen area was conducted. Drawers and cabinets were opened and the items enclosed were reviewed at this time. Drawers housing knives and sharps were observed to be locked and made inaccessible to the residents at this time. Cleaning agents, bleach, and other supplies were observed to be locked and made inaccessible to the residents at this time. A review of the facility food supply was conducted. A review of the facility's 2-day perishable foods and 7-day nonperishable foods was conducted to make sure that there were sufficient quantities on hand at all times. Medication cabinet, located in the kitchen area, was reviewed. Policies and procedures involving handling, dispensing, and documentation of the resident medications were discussed with the facility staff at this time. A review of the facility Medication Administration Record and dispensing log was conducted. Medication cabinet was observed to be locked and made inaccessible to the residents at this time. Living room, dining area, and all other areas intended for resident use were observed to furnished and maintained in compliance at this time and able to meet the needs of the residents. A tour of the resident bedrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: ROBUST CARE HOME, LLC	FACILITY NUMBER: 392700915
	VISIT DATE: 11/15/2023

NARRATIVE

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A tour of the resident restrooms was conducted. Grab bars and non skid mats were observed to be present and in good repair at this time.
Hot water temperatures were taken to make sure that they measured within the allowed range of 105-120 degrees at all times.
Laundry room was observed to be unlocked but did not house any detergents, soaps, or bleach at this time. It was learned that all cleaning and laundry supplies were separately locked and made inaccessible to the residents at all times.
Linen closet was reviewed. Bed sheets, linens, and towels were observed to be sufficient and able to meet the needs of the residents at this time.
A tour of the garage area was conducted. Additional food storage units were observed to be present and in good repair at this time. Additional nonperishable food supplies were observed to be present along with emergency food supplies as well.
First aid kits were observed to be present and contained all of the required components at this time.
Fire extinguishers were observed to be placed throughout this facility and were inspected by the local fire authority, Armor Fire, on 07/12/2023 and found to be in compliance at this time.
A tour of the exterior grounds for this facility was conducted. A review of the facility perimeter fence, side gates, and exits was conducted.
A review of (4) resident files was conducted and noted on the LIC 858.
A review of (4) resident staff files was conducted and noted on the LIC 859.

The following forms and documents were requested to be updated and submitted into CCL in order to update this facility file:

LIC 308
LIC 400
LIC 500
LIC 610

There were no deficiencies observed or cited during today's annual visit.

Exit Interview

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

LIC809 (FAS) - (06/04)

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