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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800397
Report Date: 10/08/2021
Date Signed: 10/08/2021 06:18:13 PM

Document Has Been Signed on 10/08/2021 06:18 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:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:21 PM
MET WITH:Richard CarinoTIME COMPLETED:
03:25 PM
NARRATIVE
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While at the facility, Licensing Program Analyst (LPA) Martha Guzman Chavez initiated a Case Management – Deficiencies visit. Licensee Richard Carino was present for the duration of the visit. Previously, LPA Kelly Dulek had observed deficiencies and those deficiencies are now being addressed during this visit.

On 05/18/2020, LPA Dulek had reviewed Client #1 (C1)’s daily care notes from the time period of 02/01/2020 – 04/21/2020. Upon review of these records, LPA noted nine (9) different occasions where C1 engaged in aggressive behavior, harming themselves, staff, or destroying property. LPA also noted eight (8) times C1 eloped from the facility, one (1) hospital visit, one (1) incident of self-harm, and on two (2) occasions, C1 made accusations of abuse against the facility staff. Upon review, none of these incidents were reported to the Regional Office. During a Zoom meeting that took place on 06/17/2020, Administrators Christian Carino and Richard Carino confirmed these incidents were not reported. Additionally, another incident was brought up that was not documented in C1’s daily notes, nor reported to CCL or Tri-Counties Regional Center (TCRC) involving C1 attempting to run into the street into oncoming traffic. During this incident, Staff #1 (S1) held C1 in a bear hug.

During the 06/17/2020 Zoom meeting, CCL and TCRC discussed with Administrators training facility staff in safe intervention techniques. Administrators acknowledged understanding of reporting requirements and ongoing staff training needs at that time.

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. Exit interview conducted. A copy of the report and appeal rights were provided.

(...Continued 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)
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Document Has Been Signed on 10/08/2021 06:18 PM - It Cannot Be Edited


Created By: Martha Guzman-Chavez On 10/08/2021 at 02:23 PM
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: 10/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/08/2021
Section Cited
CCR
80061(d)

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80061 Reporting Requirement (d) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours as required by Welfare and Institutions Code Section 15630(b)(1).
This requirement is not met as evidenced by:
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Administrator has agreed to provide training with an approved vendor for all facility staff on Mandated Abuse reporting and AB 40. Administrator will schedule the training and provide details (trainer name & information, date, topics to be covered) to LPA by 10/15/2021. Training to be held by 10/31/2021.
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Based on record review and interview, the licensee did not report 2 (two) incidents of alleged physical abuse to CCL, Regional Center, or the local law enforcement, which poses an immediate risk safety risk to clients in care.
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Type A
10/08/2021
Section Cited
CCR80064(a)(3)

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80064 Administrator - Qualifications and Duties (a) The administrator shall have the following qualifications: (3) Knowledge of and ability to comply with applicable law and regulation.

This requirement is not met as evidenced by:
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Administrator has agreed to schedule a training with an approved vendor on section 80064. Administrator will schedule the training and provide details (trainer name & information, date, topics to be covered) to LPA by 10/15/2021. Training to be held by 10/31/2021.
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Based on observation and interview, the Administrator had knowledge of but did not report incidents which occurred in the facility, including medical emergencies, unusual incidents, and allegations of abuse, which poses an immediate health and safety risk to clients in care.
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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:Desaree Perera
LICENSING EVALUATOR NAME:Martha Guzman-Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/08/2021 06:18 PM - It Cannot Be Edited


Created By: Martha Guzman-Chavez On 10/08/2021 at 02:27 PM
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: 10/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/08/2021
Section Cited
CCR
80061(b)(1)(E)

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80061 Reporting Requirements (b) Upon the occurrence, during the operation of the facility…a report shall be made to the licensing agency within the agency's next working day…a written report…shall be submitted to the licensing agency within seven days following the occurrence of such event. (1) Events reported shall include the following: (E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.
This requirement is not met as evidenced by:
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Administrator has agreed to provide training with an approved vendor for all facility staff reporting requirements 80061. Administrator will schedule the training and provide details (trainer name & information, date, topics to be covered) to LPA by 10/15/2021. Training to be held by 10/31/2021.
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Based on record review and interview, the licensee did not report at least 20 incidents which occurred with C1 during the time period of 02/01/2020 – 04/21/2020, which poses a potential safety & personal rights risk to clients in care.
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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:Desaree Perera
LICENSING EVALUATOR NAME:Martha Guzman-Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2021


LIC809 (FAS) - (06/04)
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