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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800874
Report Date: 10/07/2022
Date Signed: 10/07/2022 05:00:14 PM

Document Has Been Signed on 10/07/2022 05:00 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 #1FACILITY NUMBER:
565800874
ADMINISTRATOR:RICHARD T. CARINO IIFACILITY TYPE:
735
ADDRESS:4431 BEAUMONT AVENUETELEPHONE:
(805) 488-8504
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY: 4CENSUS: 4DATE:
10/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:53 PM
MET WITH:Christian Ryan CarinoTIME COMPLETED:
02:35 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) KaSandra Lopez conducted an unannounced Required 1 Year inspection at the facility today. The LPA met with the caregiver and informed him of the reason for today's visit. When the LPA arrived there was one caregiver and four clients present. Co-Administrator Christian Ryan Carino arrived during the inspection.

This annual had a specific emphasis on infection control practices and procedures. The facility is vendored by Tri-Counties Regional Center as a level 3 home. The LPA and caregiver toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed:

KITCHEN: At 12:58 PM, the kitchen and food storage areas were observed. Kitchen appliances were in operable condition. Knives are stored in a locked drawer. The facility has a sufficient supply of perishable and non-perishable food. Medications are stored in a locked cabinet in the kitchen.

COMMON SPACES: At the time of the visit, living room and dining room furniture was observed to be in good condition. The fire extinguisher is fully charged and last serviced on 10/11/2021. At 1:02 PM, the smoke detectors in the home and bedrooms were tested and were operational. The carbon monoxide detector was not operational during the inspection and is an enclosed unit of which the battery cannot be replaced. Cleaning supplies are stored in locked cabinets in the garage. There is covered outdoor seating for client use. The LPA observed the latch on the gate on the right side of the home to be broken and the lock on the storage shed in the backyard to be broken also.

BEDROOMS: There are four client bedrooms which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting.



Report continued on LIC 809-C.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2022
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 5
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 #1
FACILITY NUMBER: 565800874
VISIT DATE: 10/07/2022
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
RESTROOMS: The facility has one common hallway restroom and a common restroom which is also connected to a client room. Restrooms were observed to be clean and sanitary with hand soap, toilet paper and paper towels. At 1:14 PM, the hot water temperature in the common restroom connected to a client room measured at 113 degrees F.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Co-Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening. LPA observed all staff to be wearing masks. The LPA observed an adequate supply of Personal Protective Equipment (PPE). The facility’s cleaning protocol is sufficient. Infection control signs were posted at the entry, throughout the facility, and in the restrooms. 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’s policies and procedures as it pertains to infection control are adequate.

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 via email.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 10/07/2022 05:00 PM - It Cannot Be Edited


Created By: Kasandra Lopez On 10/07/2022 at 02:01 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 #1
FACILITY NUMBER: 565800874

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1503.2

§1503.2 Carbon monoxide detectors required; inspection
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.
This requirement is not met as evidence by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above as the facility did not have a functioning carbon monoxide detector which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/08/2022
Plan of Correction
1
2
3
4
The Co-Administrator shall submit proof by 10/08/2022 that the home has a functioning carbon monoxide detector or be subject to possible civil penalties.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2022


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 10/07/2022 05:00 PM - It Cannot Be Edited


Created By: Kasandra Lopez On 10/07/2022 at 02:17 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 #1
FACILITY NUMBER: 565800874

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
0087 Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above as the right side gate has a broken latch and the shed has a broken lock which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/08/2022
Plan of Correction
1
2
3
4
The Co-Administrator agrees to fix the gate and shed lock and provide proof to CCL by 10/08/2022.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2022


LIC809 (FAS) - (06/04)
Page: 5 of 5