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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601553
Report Date: 09/21/2022
Date Signed: 09/21/2022 12:40:51 PM

Document Has Been Signed on 09/21/2022 12:40 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CALIFORNIA MENTOR - MEADCLIFF HOMEFACILITY NUMBER:
198601553
ADMINISTRATOR:CHRIS SCHLANSERFACILITY TYPE:
734
ADDRESS:23612 MEADCLIFF PLACETELEPHONE:
(909) 274-7620
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY: 5CENSUS: 5DATE:
09/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:42 AM
MET WITH:Giovanni Camponovo, Program DirectorTIME COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with RN Cristal Parra and explained the purpose of the visit. Program Director Giovanni Camponovo arrived later. This facility is licensed as an Adult Residential Facility for Persons with Special Healthcare Needs (ARFPSHN) vendored by San Gabriel/Pomona Regional Center. The facility serves five (5) developmentally disabled clients ages 18 and above; of which five (5) may be bedridden. A total of 14 staff members provide care and supervision to the clients. The facility is a single-story home that contains five (5) bedrooms fully equipped with mechanical lifts, two (2) bathrooms fully equipped with mechanical lifts, a living room, family room, kitchen, dining area, laundry room, office, backyard/shaded patio areas, and attached garage. The last fire drill was conducted on 9/16/2022 & the last fire inspection was completed on 7/5/2022. Administrator certificate expires 9/6/2023.
OBSERVATIONS:
  • The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Smoke and carbon monoxide detectors are operational. The facility is equipped with a sprinkler system. The facility has two (2) fully charged fire extinguishers.
  • COVID-19 Infection Control Practices and signs that promote hand washing, cough/sneeze etiquette and physical distancing were observed in the entrance, common areas, hallways, bathrooms and client rooms. There is a screening station at the entrance of the facility to screen visitors. Each client room is designated as a COVID-19 isolation room if needed. Facility has an Infection Control & COVID-19 Mitigation Plans.
  • Oxygen tanks were observed to be secured on stands. The back-up power supply is located in the garage. Mechanical lifts in bedrooms and bathrooms are operational.
  • Client files have Individual Health Care Plans (IHCP). 30-day supply of client medications were locked, documented properly, and given as prescribed.
  • The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food.
  • A posted Emergency Disaster Plan was observed. Facility has an adequate 30-day+ supply of Personal Protective Equipment (PPEs), emergency supplies, and daily consumables supplies. Cleaning supplies and toxic substances are inaccessible to clients.
  • Two (2) staff (S1 & S2) have criminal record clearances but are not associated to the facility. Guardian Transfer request was completed today and the deficiency was cleared.
Per California Code of Regulations, Title 22, a deficiency was cited.
Exit interview was conducted with Program Director. A copy of the report and appeal rights were issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2022
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 09/21/2022 12:40 PM - It Cannot Be Edited


Created By: Noemi Galarza On 09/21/2022 at 12:16 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CALIFORNIA MENTOR - MEADCLIFF HOME
FACILITY NUMBER: 198601553

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(2)
80019 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 80019(f) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that staff (S1) and (S2) are not associated to the facility; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/21/2022
Plan of Correction
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Licensee submitted via Guardian a transfer request to associate staff (S1) and (S2) to the facility during the visit. The citation was cleared today.
****CLEARED
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2022


LIC809 (FAS) - (06/04)
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