134601955-3-27-2024-08-AS-CLOZ-D3RTWG-20240327150531

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 134601955
Report Date: 03/27/2024
Date Signed: 03/27/2024 03:06:30 PM

Document Has Been Signed on 03/27/2024 03:06 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	ARC IV DEVELOPMENT CENTER		FACILITY NUMBER:	134601955
ADMINISTRATOR:	MARIA NEGRETE		FACILITY TYPE:	775
ADDRESS:	298 E. ROSS AVE		TELEPHONE:	(760) 353-7440
CITY:	EL CENTRO	STATE: CA	ZIP CODE:	92244
CAPACITY: 85		CENSUS: 22	DATE:	03/27/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Sherri Gutierrez, Day Program Supervisor		TIME COMPLETED:	02:00 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) Carmen Lopez conducted an unannounced required Annual Inspection. The program file was reviewed prior to the visit. LPA Lopez identified herself, was granted entry by receptionist Maggie Bravo. LPA discussed the purpose of the visit with Sherri Gutierrez, Day Program Supervisor. According to the Day Program's license, there may be a maximum of 85 clients all of whom may be ambulatory and 10 of whom may be non-ambulatory in at any given time at the program site. During today’s inspection, the facility’s current census is 22 clients attending the day program. There were 22 clients present at the facility site during the inspection. LPA, accompanied by Day Program Supervisor Gutierrez, toured the interior and exterior of the program, and inspected each room. The program was clean, sanitary and in good repair. Pathways were free of obstruction and slip hazards. The program had the required furnishing. Doors, windows, and toilets were in working order. Extra sets of linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, visitation, meetings, and activities. The facility’s ambient internal temperature was comfortable and compliant, at 75 degrees Fahrenheit (F). Hot water temperature at taps accessible to clients measured as follows: sink in restroom #1 delivered hot water at 118.9 degrees F; sink in restroom #2 delivered hot water at 136.8 degrees F; and hot water in restroom #3 delivered hot water at 105.1 degrees F. The day program did have snacks available for clients if needed, but clients opt to bring food from home or purchase food while at program. Dining equipment and utensils were present, and all safely stored. There were no toxic chemicals/poisons accessible to clients. Medications were properly labeled, as required, and stored in locked cabinet, which LPA inspected. The facility-maintained medication logs which LPA reviewed. [CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024

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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Document Has Been Signed on 03/27/2024 03:06 PM - It Cannot Be Edited

Created By: Carmen Lopez On 03/27/2024 at 01:36 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ARC IV DEVELOPMENT CENTER	FACILITY NUMBER: 134601955
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

82088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 1 out of 3 faucets did not attain their hot water temperature less than the required regulated temperature which posed a potential safety risk to 22 persons in care.
	POC Due Date: 04/11/2024
	Plan of Correction
1 2 3 4	Staff will be submitting a work order to their maintenance department to lower their hot water temperature. Once the hot water has been reduced and tested, they will take a photo of the temperature along with their completed work order and submit to LPA by POC due date, 04/11/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Jennifer Lott

LICENSING EVALUATOR NAME:

Carmen Lopez

LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024

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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ARC IV DEVELOPMENT CENTER	FACILITY NUMBER: 134601955
	VISIT DATE: 03/27/2024

NARRATIVE

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[CONTINUED FROM LIC 809]

No pools or bodies of water on the premises. Per Day Program Supervisor Sherri Gutierrez, no firearms or ammunition are kept at the day program. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present (04) and serviced within the last 12 months. First aid kit was complete and readily accessible.

LPA interviewed staff, and reviewed staff and client records. During today’s visit there were 22 clients on the facility premise. LPA was unable to interview clients due to their inability to verbally communicate. LPA interviews did not raise any licensing concerns. The files which LPA reviewed contained required documents. Confidential records were stored in locked areas. Required licensing postings were observed in a visible area of the program.

There was a deficiency observed and will be cited during today's annual inspection. The deficiency may be found on the LIC809-D page of this report.

An exit interview was conducted with Day Program Supervisor Sherri Gutierrez to whom a copy of this report along with the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit. The signature below confirms the documents were received.

LPA requested Day Program Supervisor Gutierrez to submit a current Designation of Administrative Responsibility LIC 308, Personnel Report LIC 500, Emergency Disaster Plan LIC 610-D, and Residential Infection Control Plan LIC 9282 (6/23), to the licensing office within 10 business days. LPA provided blank forms to the Day Program Supervisor Gutierrez and informed her that forms are also available at www.ccld.ca.gov.

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024

LIC809 (FAS) - (06/04)

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