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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610348
Report Date: 12/23/2024
Date Signed: 12/23/2024 01:57:58 PM

Document Has Been Signed on 12/23/2024 01:57 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 S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:CLUB RANCHO MANOR INCFACILITY NUMBER:
197610348
ADMINISTRATOR/
DIRECTOR:		JEROME VIRAYFACILITY TYPE:
740
ADDRESS:3618 CLUB RANCHO DRIVETELEPHONE:
(323) 680-0844
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 6CENSUS: 5DATE:
12/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Stephanie DomingoTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit on 12/23/2024 and was greeted three caregiver at 10:00 am. LPA stated the purpose of the visit was to conduct an annual inspection. The caregiver confirmed there are five residents. The facility is licensed for a total of six non-ambulatory residents of which two can be bedridden. The Administrator, Stephanie Domingo arrived at 11:00 am.

LPA Spaeth and the Administrator toured the location at 10:00 am until 10:40 am.

Common Areas – LPA observed the family room, kitchen, and dining room are combined. The family room contained comfortable seating and a television. The dining room section contained a dining room table and chairs.

Kitchen – LPA observed a two-day supply of perishable food and a seven-day supply of non-perishable food items. The medications are locked in a kitchen cabinet. The knives were locked in a kitchen drawer. A fire extinguisher was located in the kitchen area. LPA observed a resident's medication is stored in the refrigerator but is not locked in a safe location.

Staff Room - LPA observed the staff was not locked but there were no safety hazards located in the room.

Laundry Room – The laundry room was locked and contained washer/dryer, laundry soap, and cleaning solutions.

Hallway – Clean linens are stored in cabinets.

Continued on 809-C

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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 S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: CLUB RANCHO MANOR INC
FACILITY NUMBER: 197610348
VISIT DATE: 12/23/2024
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Garage - LPA observed the garage was locked. An additional freezer is located in the garage and contained additional frozen food items.

Resident Bedrooms - There are four resident bedrooms which are furnished with a bed, linens, night stand, chest of drawers and a closet. Two residents are currently residing in the master bedroom (Bedroom #3) .

Bathrooms – There are two bathrooms in the facility which contained hand soap, paper towels, slip resistant mat, and a trash can.

Water Temperature - LPA tested the water temperature at 10:30 am which was 112.0 degrees F.

Backyard - Comfortable outdoor seating is provided for the residents. The side gate leading from the backyard to the front yard was not locked.



Smoke/Carbon Monoxide Detectors – The detectors were tested at 10:50 am and were operable.

Medications - LPA observed the medications are locked in a kitchen cabinet.


Auditory Device - At 10:25 am, LPA observed there was not an auditory device when exiting the master bedroom (#3) to the backyard.


LPA reviewed residents' records at 11:00 am until 11:45 am. LPA reviewed staff records at 12:15 pm until 12:40 pm LPA reviewed resident medications at 1:00 pm. There were no issues when reviewing the records.

Based upon the Title 22 regulations, the following deficiencies have been issued.

Exit interview conducted, appeal rights discussed, and a copy of the report was given.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
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Document Has Been Signed on 12/23/2024 01:57 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 12/23/2024 at 12:26 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: CLUB RANCHO MANOR INC
FACILITY NUMBER: 197610348

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above. LPA observed a resident's medication located in the refrigerator was not locked in a safe area which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/24/2024
Plan of Correction
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The Administrator will send a snapshot of the medication safely locked in the refrigerator.
Type A
Section Cited
CCR
87705(j)
Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above. LPA observed the master bedroom's (Room 3) exit to the backyard did not contain an auditory device which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/26/2024
Plan of Correction
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The Administrator will send LPA Spaeth a video of the auditory device properly working from the master bedroom.
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:Troy Agard
LICENSING EVALUATOR NAME:Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:
DATE: 12/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/23/2024


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