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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850511
Report Date: 10/09/2024
Date Signed: 10/09/2024 01:59:17 PM

Document Has Been Signed on 10/09/2024 01:59 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 NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:A PEACEFUL PLACE ON RICE RANCH RD LLCFACILITY NUMBER:
425850511
ADMINISTRATOR/
DIRECTOR:		CASTRO, ROSAFACILITY TYPE:
740
ADDRESS:711 E RICE RANCH RDTELEPHONE:
(805) 714-0579
CITY:ORCUTTSTATE: CAZIP CODE:
93455
CAPACITY: 6CENSUS: 0DATE:
10/09/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Rosa Castro, Licensee/DirectorTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On 10/09/2024, Licensing Program Analyst (LPA) Brian Phillips arrived at the facility above to conduct a scheduled, required Pre-Licensing inspection visit and Comp III for new License of a Residential Care Facility for the Elderly (RCFE). When the LPA arrived, they were greeted by Licensee/Director Rosa Castro and informed them of the reason for the visit.

On 05/09/2024, applicant/Licensee participated in COMP II. The facility has an approved capacity for Six (6) residents an age range of 60 and over. The facility is cleared for Six (6) Non-Ambulatory residents, of which one (1) may be bedridden with a Hospice Waiver for Two (2) residents. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

The LPA inspected the food service area and observed that knives/sharp instruments will be stored in locked drawers inaccessible to clients. All appliances were in operable condition and looked clean/in good repair. Appliances such as microwaves, refrigerators, stoves, etc. are clean and operating properly. Food utensils, dishes, glasses, etc. are clean and in good repair with no cracks or chips. Furniture is room/resident appropriate, clean and in good repair. All rooms are appropriately furnished for their intended use such as bedrooms, dining rooms, kitchens, living rooms, etc. Hot water temperature is maintained between 105-120 degrees Fahrenheit. Outdoor activity spaces have shaded areas and furnished for outdoor use. Each resident has an adult bed with a mattress, pad, bedsprings, and pillow, which are clean and in good repair. Each bed is fitted with sheets, pillowcase, blankets, and bedspread that are clean and in good repair. Each resident has adequate dresser and closet space for clothing and other belongings that includes at least two drawers or adequate dresser space. The facility has a sufficient supply of linens to permit weekly changing or more often to always insure clean linens for residents. Equipment and supplies for resident personal hygiene is available and on site. Activity supplies are available for residents. As the facility has an approved fire clearance for a maximum of six (6) residents, there is no signal system required or observed by LPA. Continued on 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE: DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: A PEACEFUL PLACE ON RICE RANCH RD LLC
FACILITY NUMBER: 425850511
VISIT DATE: 10/09/2024
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Refrigerator and freezer are maintained at an appropriate temperature Fahrenheit. Food storage and preparation areas, including pantries, cupboards, counters, etc., are clean and appropriate for food preparation. The food service area was clean and sanitary, with covered trashcans and operating ventilation systems. No toxic substances are stored in any food preparation or storage area, and all cleaning supplies for the kitchen are kept in a separate area than the food supplies. There is enough tableware and utensils for all clients living in the facility, and enough equipment for the storage, preparation, and service of food. A locked storage area for central storage of medications is available. Cleaning supplies will be kept in areas separate from where food supplies are stored. Walls, ceilings, floors, carpeting, window screens, and areas around the facility are clean, painted and/or in good repair. There are locked storage area(s) for poisons, toxic, cleaning solutions, disinfectants, etc. Fire extinguishers and smoke detectors operate properly. Doors, stairways, and passageways are unobstructed. There are no pools/bodies of water on the physical plant of the facility as observed by LPA. During the inspection, LPA did not observe any firearms that would require trigger locks, locked and inaccessible, or firing pins removed.

At the time of the visit, all common areas/interior rooms of the facility were observed to be appropriately furnished, with all furniture in good condition. There are activity materials in the common areas of the facility in good repair and operating condition. The facility maintained a comfortable temperature in all areas inspected. Smoke detectors and carbon monoxide detectors were tested and operational at the time of the visit. The fire extinguishers in all buildings inspected were fully charged and recently purchased in 2024. The LPA observed required postings throughout all common spaces. All window screens were in good repair in all the areas comprising the facility. There is appropriate lighting in all the common areas of the facility. All passageways through the common areas of the facility were free of obstruction, with changes in incline having ramps and/or sturdy hand railings/stair chair accessibility devices. This facility is one (1) story throughout and therefore there are no stairways for clients to utilize. The facility is completely enclosed with a main entrance door and an emergency exit at the rear of the facility. There is a main entrance into the facility on a public street. The facility has walls surrounding the interior of the facility. There are no bodies of water on the facility premises. There is an outdoor activity space for clients equipped with furniture for resident use and shade. The outdoor activity space is completely enclosed by fencing and latching gates. The designated laundry area is located in the interior of the facility with the storage of cleaning products locked and inaccessible to clients, away from food products. There was emergency food and water in the garage area which was observed to be in good condition. Cleaning supplies, disinfectants, and other items that could pose a danger to clients are kept in areas inaccessible to clients. Continued on 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024
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 NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: A PEACEFUL PLACE ON RICE RANCH RD LLC
FACILITY NUMBER: 425850511
VISIT DATE: 10/09/2024
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The facility restrooms were sanitized and in operating condition while the LPA toured the facility. Restrooms in the facility that included soap, paper towels, required postings, and clean trashcans with closed lids. All restrooms were sufficiently stocked with soap, paper towels, and additional supplies; towels and washcloths are not shared. The hot water temperature was measured in the restrooms at the appropriate degrees Fahrenheit as per the regulations between 105-120 degrees Fahrenheit. There are an adequate number of toilets per resident in the facility. Nightlights are installed as observed by LPA. All toilets and hand washing areas are maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences are available accommodate any physically handicapped residents who need such items. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Designated resident rooms in the facility have bed/beds, nightstands, and lights and nightstand lamps to provide sufficient lighting. Each closet in all the resident rooms has extra pillows, clean/fresh linens, and appropriate incontinence materials if applicable for any resident. The resident bedrooms are big enough for all beds, furniture, and any resident assisting device a resident might need such as a wheelchair or a walker. Each room has sufficient lighting for each resident. The facility has provisioned to each resident of furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene.

An emergency exiting plan and emergency phone numbers posted in an appropriate place. A current disaster and mass casualty plan maintained at the facility. First-aid supplies, which include sterile first-aid dressings, bandages, adhesive tapes, scissors, tweezers, thermometer, antiseptic solution, and a current first-aid manual, are maintained. Administrator’s records, employees and resident records will be maintained at the facility and available for review by the LPA as employees are hired and residents accepted into the facility. The facility will comply with the organization’s standards for health screening, TB clearance, staff training, criminal background clearance and transfer requests. Admission agreements and needs and services (ANS) plan will be maintained for each resident and/or their authorized representative.

A Component III Orientation was completed by LPA during this Pre-Licensing Inspection visit to the facility above on 10/09/2024. This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when 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. Copy of this report provided.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024
LIC809 (FAS) - (06/04)
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