306006164-5-19-2022-22-AS-PVEZ-CEKPXW-20220519114257

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006164
Report Date: 05/19/2022
Date Signed: 05/19/2022 11:43:05 AM

Document Has Been Signed on 05/19/2022 11:43 AM - 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	RUBY COTTAGE		FACILITY NUMBER:	306006164
ADMINISTRATOR:	BRAVO, VENUS S		FACILITY TYPE:	740
ADDRESS:	24182 MCCOY RD		TELEPHONE:	(949) 583-1996
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY: 6		CENSUS: 5	DATE:	05/19/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Arnold Bravo - Administrator		TIME COMPLETED:	12:00 PM

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Licensing Program Analyst (LPA) Patricia Velazquez conducted an announced Pre-Licensing visit with Component III Orientation to Ruby Cottage. LPA Velazquez conducted the visit with Administrator Arnold Bravo. An initial application to operate a Residential Care Facility for the Elderly (RCFE) was submitted to the Central Applications Bureau (CAB) on 03/18/2022 for a capacity of 6 non-ambulatory residents.

LPA Velazquez along with Administrator Bravo observed the following:

Structure:
Facility is a one story house with 5 resident bedrooms, 4 bathrooms, living room, family room, dining area, and kitchen. The facility has a light yellow stucco exterior with beige trim. There is an attached 3 car garage. There is a front yard comprised of grass with trees and plants as well as a cement walkway. The backyard has a shaded concrete area with seating for residents as well as a grassy area with trees and plants. The exit gate on the exterior of the home had a self-closing and self-latching mechanism.
Signal System:
The facility's central heating and air conditioning is controlled by a thermostat located in a hallway.
Bedrooms Residents:
All bedrooms accommodate non-ambulatory residents. Emergency flashlights were present in the facility. The resident bedrooms accommodate the residents' furnishings. All the required furnishings were present in each resident room.
Bathrooms:
All bathrooms have a working toilet, wash basin, and walk-in shower. Grab bars and a non-skid mat were present in each bathroom.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2022

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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: RUBY COTTAGE	FACILITY NUMBER: 306006164
	VISIT DATE: 05/19/2022

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Linens and Hygiene Supplies:
Adequate supply of linens and hygiene supplies were located in a linen cabinet in a hallway as well as the resident rooms.
Appliances: Refrigerator with freezer, dishwasher, washer and dryer, microwave, 4 burner stove top, and double ovens.
Emergency Phone Numbers, Exit Plan:
Readily available for review posted on a wall in a hallway next to the kitchen.
Postings:
The Complaint poster will be posted in the entry area of the facility. Coronavirus (COVID-19) postings were observed posted throughout the facility.
Food Service and Menu:
There was an adequate supply of 7 day non-perishable and 2 day perishables present in the facility. The sample menu was available for review.
Smoke and Carbon Monoxide Detectors:
Smoke detector and Carbon Monoxide alert systems were interconnected tested and found operational.
Fire Extinguisher:
Fully charged and mounted on a wall in the kitchen.
Fire Clearance:
Approved on 04/06/2022 for 6 non-ambulatory residents.
Toxins and Sharps:
The cleaning supplies were locked and stored in a cabinet located in a hallway. The knives and other sharp items were locked in a box located in a cabinet in the kitchen.
Water Temperature:
Tested and recorded at 115.0 degrees Fahrenheit in bathroom 1, at 115.5 degrees Fahrenheit in the left sink and at 114.4 degrees Fahrenheit in the right sink of bathroom 2, at 108.8 degrees Fahrenheit in bathroom 3, and at 116.7 Fahrenheit in bathroom 4.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2022

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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: RUBY COTTAGE	FACILITY NUMBER: 306006164
	VISIT DATE: 05/19/2022

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Medications, First Aid Kit & Manual:
The First Aid kit was checked and found to be in order. The facility did not have a First Aid manual. It will be stored in a locked cabinet located in the kitchen. Medication is stored in a locked cabinet in the kitchen.
Resident and Staff Files: Resident and staff records are stored in a cabinet next to the kitchen.
Reading Material, Games, Equipment, & Materials:
The facility had materials, games, and equipment present in the facility that commensurate with their plan of operation.

Component III:
Conducted at the Pre-Licensing visit, information was provided about how to operate the facility within compliance.

The following items need to be addressed prior to licensure:

Repair or replace the cracked tile in the shower of a resident bathroom
Repair the shower door handle in a resident bathroom and ensure the door closes properly
Obtain the Complaint Poster and post in the entry area of the facility
Relocate the Ombudsman poster to the entry area of the facility
Obtain a First-Aid manual
Clean and remove grease stains in both ovens
Post handwashing instructions in each resident bathroom
Add Cough Etiquette posters throughout the facility
Obtain 2 more chairs for outdoor seating for residents
Remove the rusted bench from the side yard
Check the faucet in a resident bathroom that was spraying water in different directions onto the countertop

Facility does not appear ready for licensure. Any items noted during today’s visit are to be corrected by June 16, 2022. LPA Velazquez will conduct a subsequent Pre-Licensing visit to review the items listed above. An exit phone interview was conducted with Administrator Arnold Bravo and a copy of this report was provided at the time of this visit.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2022

LIC809 (FAS) - (06/04)

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