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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850082
Report Date: 01/24/2024
Date Signed: 01/24/2024 03:20:06 PM

Document Has Been Signed on 01/24/2024 03:20 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
WOODLAND HILLS N.ASC, 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: DATE:
01/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:08 AM
MET WITH:Cindy Baker, AdministratorTIME COMPLETED:
03:28 PM
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Licensing Program Analysts (LPAS) Jenny Olson, and Erika Miller arrived unannounced to conduct a one year required annual inspection. LPAS met with Administrator and explained the reason for the visit.

LPAS toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Kitchen: The facility has a sufficient supply of non-perishable and perishable food items. Cleaning supplies and disinfectants are stored and locked in a cabinet under the sink and inaccessible to clients. Knives are stored in a locked drawer.

Common areas: Living and dining room furniture were observed to be in good condition. LPAs observed required postings throughout the common space. The fire extinguishers were charged and last serviced on 1/18/24.

The backyard has a covered area for shade and is equipped with furniture for client use. No bodies of water noted. The washer and dryer are in the laundry room.

Restrooms: The three restrooms were clean and sanitary and in operating condition. The bathrooms were sufficiently stocked with soap and paper towels. Around 2:10 p.m. the hot water temperature measured in the bathroom at 118.2 degrees Fahrenheit.

Bedrooms: There are five (5) client rooms, which were furnished with linens and required furniture. Extra linens and towels are stored on a mobile cart and in client rooms.

Records: LPAs reviewed client and staff records from 9:00 a.m. to 1:30 p.m. LPAs reviewed five (5) client files for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, and needs and services plans. All files were complete.

Continued on 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Erika Miller
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2024
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: MOUNTAIN RIDGE HOME CORP
FACILITY NUMBER: 425850082
VISIT DATE: 01/24/2024
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LPAs reviewed five (5) staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, current first aid certification. All files were complete.

The facility is vendored by Tri-Counties Regional Center (TCRC) as an Adult Residential Facility for Persons with Special Health Care Needs. The last disaster drill was conducted on 1-4-24

Medications: Medications review began around 2:45 p.m. Medications are centrally stored and locked in various carts. Medications are labeled and checked for expiration dates. LPAs advised the Administrator to ensure that all the necessary information is properly documented on the CSMAR.

Infection Control: The facility has an infection control plan. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. The facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

LPAs interviewed 2 staff at 2:00 pm. All clients are non-verbal.

Exit interview conducted. A copy of the report was printed.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Erika Miller
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024
LIC809 (FAS) - (06/04)
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