<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800397
Report Date: 10/08/2021
Date Signed: 10/08/2021 01:51:29 PM

Document Has Been Signed on 10/08/2021 01:51 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 IIIFACILITY NUMBER:
565800397
ADMINISTRATOR:RICHARD T. CARINO IIFACILITY TYPE:
735
ADDRESS:756 PEARSON ROADTELEPHONE:
(805) 483-2236
CITY:PORT HUENEMESTATE: CAZIP CODE:
93041
CAPACITY: 6CENSUS: 6DATE:
10/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Christian CarinoTIME COMPLETED:
01:50 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Martha Guzman Chavez conducted an unannounced visit to RMC Residential Care Home III to conduct a Required Annual Inspection with focus on Infection Control. Last Annual visit was conducted on 09/16/2019. LPA was greeted and screened at the door by caregiver Gary Fernando. Administrator Christian Carino arrived at the facility at 12:40 PM and was explained the reason for the visit.

Between 12:05 PM and 12:30 PM, LPA began the physical plant tour of the common areas, kitchen area, resident bedrooms, staff room, bathrooms, and outdoor area to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

LPA observed a central entry point by the entrance designated for temperature checks and check-in for staff, residents, and visitors. LPA observed temperature at 71 degrees Fahrenheit throughout the facility. The smoke detectors and carbon monoxide detector were tested and were operational. LPA observed one (1) fire extinguisher to be fully charged. LPA observed first aid kit and manual to be complete. Medications are stored in a locked cabinet in the kitchen inaccessible to residents. LPA observed a sufficient amount of emergency food and water stored in the garage. Toxins and cleaning supplies are stored in the locked cabinet inside the garage inaccessible to residents.

OUTDOOR SPACE: LPA observed the backyard to have a covered outdoor area with a table and chairs for resident use. There is a gate on the side of the house that has doorknob that always remains unlocked. LPA observed no bodies of water accessible to residents.

KITCHEN: LPA observed the kitchen/dining area to be clean. Knives are stored in locked in the hallway closet. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food.

(...Continujed on LIC 809C...)

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Guzman-Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/08/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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 III
FACILITY NUMBER: 565800397
VISIT DATE: 10/08/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
(...Continued on LIC 809...)

BEDROOMS: LPA observed the resident bedrooms, which were furnished appropriately. Observed inside each room was a bed with clean linens, a nightstand, and adequate lighting.

RESTROOMS: LPA observed the restrooms to be clean, sanitary and in operating condition with grab bars and non-skid mats. Water temperature was checked and in compliance at 106 degrees Fahrenheit. LPA observed washing hands signs posted throughout facility.

LPA observed at least a 30-day supply of Personal Protection Equipment (PPE). The facility cleans the common areas several times a day.

If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

LPA observed CDSS PINs displayed by the kitchen easily accessible for all residents.

Pursuant to Title 22, Division 6, facility observed to be compliant with regulation. No corrections needed at this time. Exit interview conducted. A copy of the report was provided via email.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Guzman-Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2