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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002864
Report Date: 11/25/2024
Date Signed: 11/25/2024 11:47:18 AM

Document Has Been Signed on 11/25/2024 11:47 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:OLD RANCH VILLAFACILITY NUMBER:
345002864
ADMINISTRATOR/
DIRECTOR:		RONSTADT, STEVENFACILITY TYPE:
740
ADDRESS:8312 BLAYDAN CTTELEPHONE:
(831) 706-8481
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY: 6CENSUS: 5DATE:
11/25/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:05 AM
MET WITH:Kelly Conley, House Manager TIME VISIT/
INSPECTION COMPLETED:
11:50 AM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection to obtain current paperwork for the facility's regional office file. LPA met with care staff, Sherene Brown, who contacted Administrator, Steven Ronstadt, by phone. LPA spoke to Administrator who indicated he was currently out of town but House Manager, Kelly Conley, would arrive to the facility shortly.
LPA observed (1) resident to be resting in the common area. Also present, was care staff, Mishka Simons.

Currently there are (5) residents in care and (2) residents receiving hospice care. The facility is licensed for (6) residents and has a hospice waiver for (3) residents.

House Manager arrived at 11:25 am. LPA and House Manager conducted a health and safety check of the interior of the home. There were no health and safety or personal rights risks observed.

The Administrator stated he would email the requested documents to LPA by end of today.

Exit interview. Copy of report provided to the House Manager.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE: DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/25/2024
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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