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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800174
Report Date: 11/16/2021
Date Signed: 11/16/2021 02:40:40 PM

Document Has Been Signed on 11/16/2021 02:40 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:RMC RESIDENTIAL CARE HOME IIFACILITY NUMBER:
565800174
ADMINISTRATOR:RICHARD CARINOFACILITY TYPE:
735
ADDRESS:1925 BEAUFORT AVE.TELEPHONE:
(805) 483-4628
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY: 6CENSUS: 5DATE:
11/16/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Richard CarinoTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Case Management - Incident inspection at the facility today. Tri-Counties Regional Center Quality Assurance Specialist (QAS) Liz Aced-Arnett was also present. Administrator Richard Carino arrived at the home at 12:12 PM.

The reason for today's inspection is to follow up on the self reported death report received on 11/15/2021 pertaining to Resident #1 (R1) who passed away on 11/14/2021. During today's inspection, the LPA and QAS conducted interviews with Administrator Richard Carino and conducted a telephone interview with Co-Administrator Joy Carino at 12:57 PM. The LPA also reviewed facility records and obtained pertinent copies. No immediate health and safety concerns were observed during the inspection.

The LPA has determined further investigation is needed. Exit interview and report reviewed with Richard Carino. A copy of the report will be emailed.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2021
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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