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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800874
Report Date: 11/03/2023
Date Signed: 11/03/2023 02:59:53 PM

Document Has Been Signed on 11/03/2023 02:59 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 #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:
11/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Charles CarinoTIME COMPLETED:
03:00 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
At 09:00 a.m. Licensing Program Analysts (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit. When the LPA arrived, there was (1) staff and two (2) clients present. The LPA was greeted by Staff Leticio Arnaiz and informed them of the reason for the visit. Administrator Charles Carino arrived shortly after.

At 09:30 a.m., the LPA conducted a tour of the physical plant with Administrator Charles to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: Facility is a single-story residence that consists of four (4) client bedrooms, and two (2) bathrooms. The home is vendored by Tri-Counties Regional Center as a level 3 home. The LPA observed one (1) fire extinguishers at the facility, which was fully charged and last serviced 12/19/2022. Smoke alarms and carbon monoxide detectors were tested and at 9:47 a.m. and 9:49 a.m. two (2) smoke detectors in client’s bedrooms were observed to be inoperable. The LPA observed all required postings in the powdered room.

Kitchen: During the facility tour, the kitchen appeared clean and the appliances and fixtures functional. The LPA observed a sufficient supply of perishable and non-perishable food at the facility; Sharp objects were stored in a locked drawer to the left of the kitchen sink. Food is prepared based on the menu and modified as needed for individual residents. Snacks and beverages are always available for residents.
Bedrooms: The LPA observed resident bedrooms properly furnished with at least one chair, nightstand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets.
Bathrooms: The LPA observed the resident’s bathroom to be clean, and properly supplied. Residents have sufficient supplies for personal hygiene. At 09:44 a.m., the water temperature in the resident’s restroom was measured at 109.8 degrees Fahrenheit.

Report will continue on LIC809-C.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2023
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
Document Has Been Signed on 11/03/2023 02:59 PM - It Cannot Be Edited


Created By: Esther Cortez On 11/03/2023 at 02:19 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: 11/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

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 two smoke detectors were inoperable, which poses an immediate health risk to persons in care.
POC Due Date: 11/03/2023
Plan of Correction
1
2
3
4
Plan of correction has been met. Upon observation, the administrator replaced the batteries to both smoke detectors.
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:Kasandra Lopez
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2023


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 11/03/2023 02:59 PM - It Cannot Be Edited


Created By: Esther Cortez On 11/03/2023 at 02:19 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: 11/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(b)(5)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as all four clients are prescibed PRN medications and no PRN autherization letters were on file which poses a potential health and safety risk to persons in care.
POC Due Date: 11/17/2023
Plan of Correction
1
2
3
4
Administrator agrees to contact the physicians who prescribed the PRN medications and obtain signed PRN letters that indicate if the clients are able or unable to determine their own need for PRN medications and specify the PRN medication or if their doctor needs to be contacted prior to administering the PRN medication. Proof will be submitted to LPA Cortez by 11/17/23.
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:Kasandra Lopez
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
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 #1
FACILITY NUMBER: 565800874
VISIT DATE: 11/03/2023
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
Common Areas: These included the living, and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. There is a fireplace in the living room, which is covered with a screen. The facility maintained a comfortable temperature of 71 degrees. There were no obstructions and/or tripping hazards throughout the facility.

The garage: At 09:33 a.m. the LPA observed the garage, where the washer and dryer are held, and the emergency food and water is stored. Cleaning supplies and disinfectants are kept in locked cabinets in the garage. The garage is not locked.
Surrounding Grounds (Outdoors): The LPA observed appropriate outdoor furniture, with a covered shaded area for clients. There are no bodies of water on the premises.
Infection Control: Facility has a sufficient supply of Personal Protection Equipment (PPE). The facility’s cleaning protocol was sufficient. The facility's procedures as it pertains to infection control are adequate.
Medications: At 10:00 a.m. a medications review was initiated. Medications are centrally stored and locked in a cabinet in the kitchen; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. The LPA observed all clients have PRN medications and the facility does not have PRN Authorization Letters on file to indicate whether the residents are able to make their own decision or if the doctor needs to be contacted prior to assisting the residents with the PRN medications.
Record Review: At 11:08 a.m., a review of facility files was initiated. Facility records are stored in a locked cabinet in the enclosed patio. The LPA observed documentation of Infection Control, Disaster prevention and last fire drill (conducted on 11/01/2023). The LPA obtained Client Roster, Staff Roster, and a copy of the Insurance liability. The LPA reviewed five (5) of six (6) staff files and four (4) out of four (4) client files. All documents reviewed appeared complete and current.
Interviews: During the visit at 1:55 p.m. the LPA conducted two (2) staff interviews. The LPA could not conduct any client interviews due to them being non-verbal. No immediate concerns voiced at this time.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):Civil penalty issued for the amount of $500. Failure to correct the deficiencies may result in additional civil penalties.

Exit interview conducted and copy of the report and appeal rights provided to Administrator Charles Carino.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5