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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800397
Report Date: 10/10/2022
Date Signed: 10/10/2022 05:12:38 PM

Document Has Been Signed on 10/10/2022 05:12 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:
10/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Ryan CarinoTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Angel Ascencio conducted an unannounced required annual visit
to the facility above. LPA Ascencio met with the Administrator Ryan Carino and explained the
reason for the visit. At 10:10 a.m., the LPA, along with the Admin toured the physical plant areas
inside and outside to ensure that there are no health and safety hazards.

BEDROOMS: All client rooms are set up with beds, night stands, lamps, chests of drawers,
chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean
linen; which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a
bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for
easy passage between the beds. In addition, no bedroom was used as a passageway to another
room, bath or toilet. There are three (3) total bedrooms for resident use – all rooms are shared.

RESTROOMS: There are two (2) total bathrooms at the facility. One (1) is
designated as a staff bathroom, 1 is in the common hallway for all to use. The clients bathroom has a shower with non-skid materials. The toilet and showers have grab bars. The hot water temperature was tested in the bathrooms and kitchen. Areas were found to be within the range of 105*F and 120*F.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and
good condition. At the time of the visit, common seating area and dining room furniture was
observed to be in good condition. Chairs were observed to be at least 6 (six) feet apart for social
distancing. The LPA observed the required postings in the common hallway. The fire extinguisher was
observed to be serviced within the last year.

Continued on LIC 809 - C
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2022
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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Document Has Been Signed on 10/10/2022 05:12 PM - It Cannot Be Edited


Created By: Angel Ascencio On 10/10/2022 at 11:13 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: RMC RESIDENTIAL CARE HOME III
FACILITY NUMBER: 565800397

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as a kitchen knife, scissors and a peeler were in an unlocked, kitchen drawer accesible to clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/11/2022
Plan of Correction
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Amin will conduct all staff training. Admin submit training materials and attendee of the training to CCL by 10/14/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kristin Heffernan
LICENSING EVALUATOR NAME:Angel Ascencio
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/10/2022 05:12 PM - It Cannot Be Edited


Created By: Angel Ascencio On 10/10/2022 at 11:13 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: RMC RESIDENTIAL CARE HOME III
FACILITY NUMBER: 565800397

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as the office window screen was not available to be put back into the window which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2022
Plan of Correction
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Admin stated they will have the window screen cover repaired. Admin will send pictures to CCL by 10/21/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kristin Heffernan
LICENSING EVALUATOR NAME:Angel Ascencio
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2022


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 III
FACILITY NUMBER: 565800397
VISIT DATE: 10/10/2022
NARRATIVE
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The facilities smoke detectors and carbon monoxide alarms were tested throughout the facility and seemed to work properly at the time of visit. Medication was observed to be locked and contained 30 days of medication. The garage, which has laundry equipment, was observed locked contained laundry supplies. The outdoor patio has a covered outdoor area equipped with furniture for client use. There were no bodies of water noted.

KITCHEN: Kitchen knives are stored in the locked, hallway closet. The supply of dishes, utensils, pots, pans and drink ware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the
refrigerator was maintained at 40*F. The supply of perishable and nonperishable food is adequate. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils.
Appliances in the kitchen were clean and all appeared functional. Trash cans had tight fitting lids.
Kitchen, laundry and house cleaning supplies are stored in a locked cabinet located in a locked
room by the kitchen. No flies or other vermin were observed.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Admin regarding the
facility’s infection control practices at 11:10 a.m. There is 1 entry into the facility. Upon entry, the
facility has a central entry point for symptom screening. The LPA noted that the facility is allowing
visitors for both indoor and outdoor visitation. The LPA observed an adequate supply of Personal
Protective Equipment (PPE) and the facility is able to obtain additional supplies as needed. The
facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility does not have a confirmed case of COVID-19 at this time. The facility’s policies and procedures as it pertains to infection control are adequate.

During facility tour, starting at 10:20 a.m., LPA observed a kitchen knife, scissors and a peeler in an unlocked, kitchen drawer accessible to clients in care. Staff stated they have all knifes locked away and were going to use this knife for lunch. At 10:35 a.m., LPA observed a missing window screen on the office window. Staff stated it has been this way for 2 weeks. The window screen was sent out for repair.

2 citations were issued during today’s visit. The following deficiencies were observed (See
LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California
Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.
Exit interview conducted. A copy of the report and appeal rights were provided to admin via email.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2022
LIC809 (FAS) - (06/04)
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