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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405800130
Report Date: 02/15/2023
Date Signed: 02/15/2023 05:38:02 PM

Document Has Been Signed on 02/15/2023 05:38 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:C.A.L.L.-RAMONA HOUSEFACILITY NUMBER:
405800130
ADMINISTRATOR:JAMI WESTFACILITY TYPE:
735
ADDRESS:3355 RAMONA ROADTELEPHONE:
(805) 466-2909
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY: 4CENSUS: 3DATE:
02/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:13 PM
MET WITH:Tryston Davis, Lead Residential TrainerTIME COMPLETED:
05:55 PM
NARRATIVE
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On 2/15/23 at 4:13 pm, Licensing Program Analyst (LPA) Chavez conducted an unannounced on-site annual infection control visit to the facility above. LPA met with Tryston Davis, Lead Residential Trainer, and explained the purpose of the visit. Lead residential trainer states that it is the Administrator Jami West’s day off.

LPA toured the facility with the lead residential trainer and observed the following: Upon entry to the facility, LPA was screened, however, the lead residential trainer was not wearing his mask properly as he had it below his chin. Additionally, all staff are wearing cloth masks and must be wearing at minimum surgical masks. This is a violation of official government orders requiring the wearing of face coverings while working under specified conditions. The facility did not protect the personal rights of clients in care to be able to receive safe and healthful accommodations in that the facility staff failed to wear face coverings properly while providing care and supervision to clients in care. Pursuant to Title 22, California Code of Regulations, the deficiency will be cited on 809-D. The facility has infection control signage throughout the facility on handwashing, cough etiquette and use of masks. The facility has soap and paper towel dispensers in resident bathrooms (2). Fire extinguishers are located in the dining room and medication room. Extinguishers are fully charged and were inspected on 11/22/22. The facility has two screen doors with tears in them. Licensee will repair/replace these and send photos to LPA by 2/22/23.


At 4:45 pm, LPA conducted the Infection Control mitigation module with the lead residential trainer.

Exit interview conducted, deficiency cited, and the report and appeal rights given to the administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2023
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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Document Has Been Signed on 02/15/2023 05:38 PM - It Cannot Be Edited


Created By: Darlene Chavez On 02/15/2023 at 05:24 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: C.A.L.L.-RAMONA HOUSE
FACILITY NUMBER: 405800130

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80072(a)(2)
80072(a)(2) Personal Rights
(a) Except for children’s client facilities, each client shall have personal rights which include, but are not limited to, the following:
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on observations, the facility failed to ensure staff were wearing face coverings properly which poses an immediate health, safety and personal rights risk to clients in care.
POC Due Date: 02/16/2023
Plan of Correction
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Staff immediately changed their masks to N95s and will look into getting surgical masks. Lead residential trainer has committed to ensuring staff are trained on infectious control and will write a statement stating the training will be conducted with all facility staff by 2/22/23. Lead residential trainer will send the statement to LPA by 2/16/23 committing that the training will be conducted by 2/22/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Kelly Burley
LICENSING EVALUATOR NAME:Darlene Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2023


LIC809 (FAS) - (06/04)
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