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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425800121
Report Date: 01/31/2022
Date Signed: 01/31/2022 12:07:11 PM

Document Has Been Signed on 01/31/2022 12:07 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:TOBY RANCH RESIDENCEFACILITY NUMBER:
425800121
ADMINISTRATOR:HELEN SAN ANTONIO98FACILITY TYPE:
735
ADDRESS:532 CABO SAN LUCAS CIRCLETELEPHONE:
(805) 349-8215
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY: 6CENSUS: 6DATE:
01/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Jonelyn San AntonioTIME COMPLETED:
12:15 PM
NARRATIVE
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On 01/31/22 at 9:50 a.m., Licensing Program Analyst (LPA) Toan Luong conducted an unannounced annual visit to the facility. LPA with Staff (S1) Jonelyn San Antonio and explained the purpose of the visit. The facility is an Adult Residential Facility with funding from Tri-Counties Regional Center.

At 9:50 a.m., LPA arrived at the facility and saw one sign on a door of the house stating no visitors were allowed. The house had multiple front entrances, and neither of the doors had any other signs. LPA advise S1 to update signs for current visitation policy and to redirect visitors to a central entrance. Upon entry, LPA was screened. LPA recommended staff have hand sanitizer near the entrance for visitors to use.
At 10:32 a.m., LPA entered the kitchen storage room adjacent to the kitchen. LPA and S1 observed a box containing two one gallon Chorlox bottles underneath a table. The box was besides cooking oil. On the table, LPA and S1 observed one Lysol canister besides 2 bottles of maple syrup. A box with two one gallon Dawn dish soap were also observed underneath the table. Cleaning products were unused and unopen. Staff explained to LPA that products were purchased from Costco and stored there temporarily. Staff removed the cleaning products. LPA and S1 observed one molding orange and lemon on the same table. The lemon was in a basket with other lemons. Staff discarded the molding fruits. The facility has a backyard with fruit trees that family members pick from but did not dispose or stored it properly.
At 11:00 a.m., LPA went over the Infection Control module and advised S1 that the facility will need to have staff fit tested with N95 when working with Covid-19 positive clients.

LPA issued citation on LIC 809D, conducted exit interview, provided appeal rights, and emailed report to the administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2022
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 3
Document Has Been Signed on 01/31/2022 12:07 PM - It Cannot Be Edited


Created By: Toan Luong On 01/31/2022 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: TOBY RANCH RESIDENCE
FACILITY NUMBER: 425800121

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80076(a)(18)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (18) All food shall be protected against contamination. Contaminated food shall be discarded immediately.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 counts which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/01/2022
Plan of Correction
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Staff discarded the molding fruits. Facility will have a designated basket for picking fruits, so that fruit will not rot on the ground.
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:Toan Luong
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 01/31/2022 12:07 PM - It Cannot Be Edited


Created By: Toan Luong On 01/31/2022 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: TOBY RANCH RESIDENCE
FACILITY NUMBER: 425800121

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80076(a)(16)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (16) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation and interview, the licensee did not comply with the section cited above in 5 counts which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/01/2022
Plan of Correction
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2
3
4
Staff removed the cleaning products and locked it in a different cabinet.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
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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:Kelly Burley
LICENSING EVALUATOR NAME:Toan Luong
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2022


LIC809 (FAS) - (06/04)
Page: 3 of 3