565800397-10-18-2024-29-AS-EMOY-DA6RTC-20241018131807

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565800397
Report Date: 10/17/2024
Date Signed: 10/18/2024 01:20:12 PM

COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/18/2024 01:20 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	RMC RESIDENTIAL CARE HOME III		FACILITY NUMBER:	565800397
ADMINISTRATOR/ DIRECTOR:	RICHARD T. CARINO II		FACILITY TYPE:	735
ADDRESS:	756 PEARSON ROAD		TELEPHONE:	(805) 483-2236
CITY:	PORT HUENEME	STATE: CA	ZIP CODE:	93041
CAPACITY: 6		CENSUS: 6	DATE:	10/17/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:32 PM
MET WITH:	Casey Carino - Administrator Richard T. Carino - Administrator		TIME VISIT/ INSPECTION COMPLETED:	04:45 PM

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Licensing Program Analyst (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit at 1:30PM. The LPA initially met with facility staff Henry Dupee. LPA explained the reason for today's visit. The Administrators, Richard Carino and Casey Carino were contacted via telephone and arrived during the visit. Entrance interview conducted.

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

Beginning at 1:35PM, 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 1:45PM and all functioned properly. The fire extinguisher was observed to be fully charged and last serviced on 12/13/2023.

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. The restrooms were sufficiently stocked with supplies and paper towels Hot water was checked in the shared client restroom and measured 111.7 degrees Fahrenheit at 1:39PM within the required range.

Report Continued on LIC 809-C 2nd Page

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: RMC RESIDENTIAL CARE HOME III	FACILITY NUMBER: 565800397
	VISIT DATE: 10/17/2024

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Report Continued from LIC 809...
LIC 809-C 2nd Page

KITCHEN: The LPA inspected the kitchen/food service area at 1:34PM. Knives and sharps were observed in a locked cabinet in the hall way. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) day perishable and seven (7) day non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates

COMMON SPACES: At the time of the visit, furniture in the common areas were observed to be in good condition. The facility maintained a comfortable temperature. The LPA observed required postings upon entry. The last emergency disaster drill took place on 08/15/2024. Activities were observed in the common areas.

GARAGE/BACKYARD: The garage is maintained locked at all times. There is a washer and dryer on premises. LPA observed an adequate amount of emergency food and water. Cleaning supplies are kept in the garage locked and inaccessible to residents in care. The backyard has a covered patio area with patio furniture including a table and chairs for resident use. All passageways were observed to be clear. LPA observed two (2) self-latching gates. There were no bodies of water noted at the time of the visit.

RECORDS: The LPA and Administrator reviewed: Client Records were reviewed beginning at 1:50PM. and personnel records at 2:15PM Six (6) client files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. Four (4) personnel files including the Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order. The LPA and Administrator reviewed P&I money at 2:31PM. for three (3) clients. Cash resources were found to be separate and intact and not commingled with facility funds or petty cash.
Report Continued on LIC 809-C 3rd page

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: RMC RESIDENTIAL CARE HOME III	FACILITY NUMBER: 565800397
	VISIT DATE: 10/17/2024

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Report Continued from LIC 809-C 2nd Page...
LIC 809-C 3rd Page

MEDICATIONS: Medications review began at approximately 2:55PM. The medications are locked in a cabinet adjacent to the kitchen. Medications for four (4) clients were reviewed. Medications reviewed were found to be self-administered as prescribed and documented on the centrally stored medication and destruction records.

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

Documents obtained during today's visit include currently copy of liability insurance, Surety bond, LIC 9020, and Staff schedule.

No deficiencies were cited during today’s inspection. Exit interview conducted. A copy of the report was provided.

**This report was originally generated under the wrong facility on 10/17/2024 inadvertently issued by error and should have originally been generated under RMC RESIDENTIAL CARE HOME III. On 10/18/2024 Licensee was notified and a copy of the report was sent for signature.**

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024

LIC809 (FAS) - (06/04)

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