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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850038
Report Date: 10/06/2022
Date Signed: 10/06/2022 12:20:56 PM

Document Has Been Signed on 10/06/2022 12:20 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:ARROYO GRANDE HOMEFACILITY NUMBER:
405850038
ADMINISTRATOR:GUADALUPE RAMIREZ HERNANDEFACILITY TYPE:
735
ADDRESS:2119 LOPEZ DRTELEPHONE:
(805) 473-5784
CITY:ARROYO GRANDESTATE: CAZIP CODE:
93420
CAPACITY: 4CENSUS: 4DATE:
10/06/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:59 AM
MET WITH:Guadalupe Ramirez, AdministratorTIME COMPLETED:
11:50 AM
NARRATIVE
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Licensing Program Analyst (LPA) De Leon conducted a case management visit to the facility above. LPA met with Administrator Guadalupe Ramirez and explained the purpose of the visit.

On a 06/22/2022 visit by LPA during a complaint investigation it was revealed that R1 was told that R1 could not have a cigarette which violated R1’s personal rights and triggered R1 to have several behavior episodes with staff at the facility on 06/10/2022, 06/12/2022 and again on 06/13/2022. The facility does allow smoking outside and violated R1’s personal rights by not allowing R1 to smoke R1’s cigarettes.

Exit interview conducted, deficiency cited, copy of report and appeal rights given.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2022
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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Document Has Been Signed on 10/06/2022 12:20 PM - It Cannot Be Edited


Created By: Rachael De Leon On 10/06/2022 at 11:33 AM
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: ARROYO GRANDE HOME
FACILITY NUMBER: 405850038

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/13/2022
Section Cited
CCR
85072(b)(6)

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(b)The licensee shall insure that each client is accorded the following personal rights. (6) To possess and use his/her own personal items, including his/her own toilet articles. This requirement was not met as evidenced by:
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Administrator agreed to review and train all staff in personal rights regulations 85072 & 80072 and provide proof of training to CCL with a current LIC 500 and all staff signatures.
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Based on interviews the licensee did not comply with the regulation above, staff refused to give R1 R1’s cigarettes which poses a potential personal rights risk to residents in care.
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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:Rachael De Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2022


LIC809 (FAS) - (06/04)
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