405801057-1-15-2025-29-AS-MRAN-DCXTUC-20250115140206

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405801057
Report Date: 01/15/2025
Date Signed: 01/15/2025 02:02:48 PM

Document Has Been Signed on 01/15/2025 02:02 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:	BAY OSOS RCFE I		FACILITY NUMBER:	405801057
ADMINISTRATOR/ DIRECTOR:	RODOLFO PACAOAN		FACILITY TYPE:	740
ADDRESS:	1663 13TH STREET		TELEPHONE:	(805) 528-4416
CITY:	LOS OSOS	STATE: CA	ZIP CODE:	93402
CAPACITY: 6		CENSUS: 3	DATE:	01/15/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:30 AM
MET WITH:			TIME VISIT/ INSPECTION COMPLETED:	02:10 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) Rankin arrived at 10:30 a.m. to conduct a one-year annual visit to the facility above. LPA met with Administrator Rodolfo Pacaoan and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit: Physical Plant & Environment Safety: The facility has 3 resident bedrooms, 1 caregiver bedroom and 2 bathrooms. Facility currently occupies 3 residents. LPA was authorized to enter and inspect facility. The facility had a smoke and carbon monoxide detector that was tested and working properly during visit. The lighting and lamps are sufficient for the use of the facility and for resident comfort. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The showers have non-skid mats. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are inaccessible to residents in care locked in cabinet in garage. The facility has sufficient space inside and outside for activities and visiting. The facility has a fenced backyard for client use and front patio has plenty of shade. The facility has telephone and internet service for resident use. Operational Requirements: The facility has a current plan of operation on file with the department. The facility has current liability insurance and expires on November 3, 2025. The facility is approved for a capacity of six. The fire clearance is granted for 6 non-Ambulatory of which one may be bedridden. Hospice is approved for three. (Continued on LIC 809-C)

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BAY OSOS RCFE I	FACILITY NUMBER: 405801057
	VISIT DATE: 01/15/2025

NARRATIVE

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Staffing: The facility currently employes 3 full time staff, and three Administrators. Staff files were reviewed. Current Administrator Certificate expires January 16, 2025, but all required documents have been submitted and approval is pending at the application bureau. Other back-up administrator certificate expires in July of 2026.

Personnel Records & Training: The facility keeps confidential files for each staff member. Staff have annual training completed for various subjects/topics and hours for 2024.

Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Facility does submit incident reports to the department when required. LPA reviewed five resident files for signed Admission Agreements.

Food Service: The facility handles and prepares food safely. The facility has 2-day perishables and 7-day non-perishables and plenty extra, to meet the food service requirement. All food is covered, stored and marked appropriately. Food, snacks and drinks are available when the residents want them. Cleaning solutions and equipment are stored separately from food supplies.

Disaster Preparedness: The current emergency disaster forms were posted. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency.

Residents with Special Health Needs: The facility does accept dementia residents in care. The facility does not currently have residents receiving Home Health services or Hospice services.

Exit interview conducted, copy of report provided.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025

LIC809 (FAS) - (06/04)

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