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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850230
Report Date: 12/28/2021
Date Signed: 12/28/2021 07:33:22 PM

Document Has Been Signed on 12/28/2021 07:33 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:A CASA RANCHFACILITY NUMBER:
425850230
ADMINISTRATOR:SORIANO, APRILYN AFACILITY TYPE:
740
ADDRESS:502 N. RANCH STREETTELEPHONE:
(650) 544-1485
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY: 6CENSUS: 2DATE:
12/28/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Aprilyn SorianoTIME COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Diaz conducted a pre-licensing visit to the facility above at 10:50am. LPA met with applicant Aprillyn Soriano and Consultant Debra Ermac and Administrator Cheryll Ate. The applicant has obtained fire clearance for (6 )non-ambulatory and (4) bedridden residents for a total capacity of (6) residents.

Beginning at 11:00am, LPA inspected the proposed facility for Fire Safety, Personal Accommodations, and Food Service. All smoke alarms and carbon monoxide detectors were functioning properly at this time. LPA observed two screens windows to be torn and needed repair.

LPA observed one fire extinguisher to be fully charged and newly purchased. Paint, windows, blinds, and floors are in good repair. There are no firearms on the premises. The common living and dining areas are clean and properly furnished. A working telephone is present. The facility has a comfortable temperature of 71 degrees.

The proposed facility has 5 resident bedrooms total. There are 4 single-occupancy bedrooms and 1 double occupancy bedroom. 4 resident bedrooms were furnished and contained beds, chairs, bedside tables and lamps. All beds have sheets, pillows, and mattress pads. 1 double occupancy bedroom was missing a night stand. There is also an ample supply of linen, towels and paper products. The proposed facility has (3) full bathrooms for resident use. Bathroom 3 needs new light bulbs and a repaired light switch. LPA observed a night-light present in the main hallway. Hot water measured at 112 degrees Fahrenheit at approx. 11:50am
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Arien Diaz
LICENSING EVALUATOR SIGNATURE: DATE: 12/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/28/2021
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: A CASA RANCH
FACILITY NUMBER: 425850230
VISIT DATE: 12/28/2021
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The kitchen contained a sufficient supply of dishes, glasses and utensils. A seven-day supply of non-perishable food is present, as well as, a seven-day supply of water. A locked medication cabinet and First aid kit was observed to be complete. There is space to lock Chemicals in the garage and under the kitchen sink and in the laundry room. Sharp items are stored in a locked kitchen drawer. Laundry room is located next to the kitchen and supplies will be stored in the locked garage cabinets. The building and grounds are free from hazard. LPA and Applicant Aprilyn Soriano completed component III


The following needs to be completed/proof submitted prior to the facility being licensed:
1. Two screen windows need to be repaired
2. Repair Light Switch and bathroom light bulbs
3. Complaint poster needs to be size 20 by 26 color
4. Missing night stand in bedroom 3


This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.
Exit interview conducted and report issued.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Arien Diaz
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2