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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850082
Report Date: 12/21/2022
Date Signed: 12/21/2022 03:59:48 PM

Document Has Been Signed on 12/21/2022 03:59 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:MOUNTAIN RIDGE HOME CORPFACILITY NUMBER:
425850082
ADMINISTRATOR:BAKER, CINDYFACILITY TYPE:
734
ADDRESS:3271 OLD HIGHWAY 246TELEPHONE:
(650) 267-9482
CITY:SANTA YNEZSTATE: CAZIP CODE:
93460
CAPACITY: 5CENSUS: 5DATE:
12/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Donna Pieprzycki, RN ConsultantTIME COMPLETED:
04:20 PM
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On 12/21/22 at 2:30 pm, Licensing Program Analyst (LPA) Chavez conducted an unannounced on-site annual infection control visit to the facility above. LPA met with Staff #1 (S1) and explained the purpose of the visit. At 2:35 pm, Donna Pieprzycki, RN Consultant, arrived at the facility, and LPA explained the reason for the visit.

LPA toured the facility with S1 and observed the following: The facility has infection control signage at the front entrance and throughout the facility on handwashing, cough etiquette and use of masks. Staff are wearing masks. The facility has soap and paper towels in resident bathrooms (2). Fire extinguishers (2) are located in the hall near the laundry room and the hall near resident bedrooms on the east end of the facility. The extinguishers are fully charged and were inspected on 12/8/22 and 12/2/22 respectively. LPA observed cleaning supplies and hand sanitizer in an unlocked cabinet in the staff bathroom which is also unlocked. Nurse consultant immediately moved supplies to the locked closet at the entryway. Nurse consultant committed to writing a statement showing that quarterly trainings with staff will be conducted on proper storage of toxins and will send statement to CCL by 12/28/22. LPA took water temperatures and from 2:59 pm to 3:05 pm, the sink’s water temperature in the residents’ bathroom near the office was 70.5F degrees. Per CCLD Health & Safety regulation water temperatures are to be between 105F and 120F degrees. Citation issued.

At 3:30 pm, LPA conducted the Infection Control mitigation module with the nurse consultant. No deficiencies cited from the module.

Exit interview conducted, deficiency cited, and the report and appeal rights emailed to the administrator and nurse consultant.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 12/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2022
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 12/21/2022 03:59 PM - It Cannot Be Edited


Created By: Darlene Chavez On 12/21/2022 at 03:44 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: MOUNTAIN RIDGE HOME CORP
FACILITY NUMBER: 425850082

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
80088 - Furniture Equipment and Supplies. (e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by::
Deficient Practice Statement
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Based on LPA’s observations, the licensee failed to ensure that the hot water temperature was at minimum 105 degrees F in resident’s bathroom which poses an immediate health and safety risk to residents in care.
POC Due Date: 12/22/2022
Plan of Correction
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Licensee will adjust water mechanism to ensure water temperature in residents’ bathroom is between 105F and 120F degrees. Licensee will send a video to CCL by end of day 12/22/22 showing the water temperature in residents’ bathroom stabilizing between 105F and 120F.
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: 12/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2022


LIC809 (FAS) - (06/04)
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