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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800174
Report Date: 11/22/2021
Date Signed: 11/22/2021 06:00:21 PM

Document Has Been Signed on 11/22/2021 06:00 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:
11/22/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Ryan CarinoTIME COMPLETED:
11:10 AM
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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. Co-Administrator Ryan Carino was at the home when the LPA and QAS arrived.

Today's inspection is a follow up to the 11/16/2021 Case Management - Incident visit regarding 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 an interview with Co-Administrator Ryan Carino and Staff #1 (S1) beginning at 10:02 AM.

Further investigation is needed. Exit interview and report reviewed with Ryan Carino. A copy of the report will be emailed.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2021
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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