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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800174
Report Date: 10/23/2023
Date Signed: 10/23/2023 11:38:07 AM

Document Has Been Signed on 10/23/2023 11:38 AM - 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:
10/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:04 AM
MET WITH:Richard, Joy, and Casey CarinoTIME COMPLETED:
11:40 AM
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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 09:04AM. The LPA initially met with facility staff Aaron Edrada. LPA explained the reason for today's visit. The Administrator was contacted via telephone and arrived at 09:30AM. Entrance interview conducted.

The facility is vendored through Tri-Counties Regional Center as a level 4i home.

Beginning at 09:40AM, the LPA, along with facility staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The following was observed:

Smoke alarms and separate carbon monoxide detector were tested at 10:59AM and all functioned properly. The fire extinguisher was observed to be fully charged and last serviced on 12/19/2022.

BEDROOMS: The LPA observed three shared client bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

RESTROOMS: One (1) restroom is designated for shared client use and one (1) is designated as a staff restroom. Client restroom is clean and sanitary and in operating condition. Hot water was checked in the shared client restroom and measured just at the minimum of the required range.

KITCHEN: Knives are stored in a locked drawer. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food.

COMMON SPACES: Living room and dining room furniture was observed to be in good condition. The LPA observed the required postings upon entry. The backyard patio contains a shaded area and is equipped with furniture for clients' use. Garage was observed to be utilized as an activity space for clients and also contained laundry area, locked chemical storage as well as extra food and emergency supply.

Report Continued on LIC 809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 10/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2023
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: RMC RESIDENTIAL CARE HOME II
FACILITY NUMBER: 565800174
VISIT DATE: 10/23/2023
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CLIENT FILES/CASH RESOURCES: LPA reviewed all five (5) client files for, but not limited to: physician's report, proof of TB test, Admission Agreement, and cash resources. All five (5) of five (5) client files reviewed were complete and contained all documentation required.

MEDICATION REVIEW: Beginning at 10:48AM, LPA reviewed medications for three (3) clients. All medications reviewed were documented and stored in compliance with regulation.

STAFF FILES: LPA reviewed five (5) staff files for, but not limited to: fingerprint background clearance, health screening, TB test, and training records. All five (5) staff files reviewed were in compliance with regulation.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are conducted quarterly, with the last drill conducted on 08/15/2023. Emergency disaster plan was observed to be complete and updated annually, however, the facility is utilizing the older form. LPA provided the updated form during the visit.

INTERVIEWS: During today's visit, LPA interviewed one (1) client and two (2) staff.

No citations issued. Exit interview conducted. A copy of the report was provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2023
LIC809 (FAS) - (06/04)
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