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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601553
Report Date: 08/22/2024
Date Signed: 08/22/2024 06:35:20 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/22/2024 06:35 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CALIFORNIA MENTOR - MEADCLIFF HOMEFACILITY NUMBER:
198601553
ADMINISTRATOR/
DIRECTOR:		CHRIS SCHLANSERFACILITY TYPE:
734
ADDRESS:23612 MEADCLIFF PLACETELEPHONE:
(909) 274-7620
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY: 5CENSUS: 5DATE:
08/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Jennifer Balvaneda, DSPTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the annual inspection on 8/22/24. LPA arrived
unannounced and met with DSP, Jennifer Balvaneda. The purpose for the visit was explained. The
Administrator, Efnan Scott, arrived shortly after to assist with the visit. This facility is licensed as an Adult
Residential Facility for Persons with Special Healthcare Needs (ARFPSHN) and is vendored by the San
Gabriel/Pomona Regional Center. The facility is licensed to serve (5) developmentally disabled adults, ages
18 and over, of which (5) may be bedridden. There is currently (5) non-ambulatory clients residing at the
facility.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools to inspect the facility and observed the following: The facility is a single story home consisting of 5 private client bedrooms, staff office, 2 bathrooms, living room, t.v. room, dining space, kitchen, laundry room, and attached garage. The backyard has a shaded area. There are no pools or bodies of water and no items obstructing the walkway. The client bedrooms are equipped with mechanical lifts. The shared bathroom is clean and sanitized. The fire extinguishers are inspected annually and is fully charged. The facility checks and documents the hot water temperature and refrigerators temperature on a daily basis. Facility has backup generators and are checked weekly. Emergency/disaster drills are conducted at least every 6 months. Medications are stored in a cart and also in the locked storage space. LPA reviewed all the clients' medications and did not observe any deficiencies. LPA reviewed all 5 client files. The files consist of the face sheet, admission agreement, consent forms, medical assessment with TB results, current IPP report, and property/valuables form. LPA also reviewed the P&I ledger for 4 out of the 5 clients. LPA checked 4 personnel records. The administrator's (Efnan Scott) certificate expired on 7/25/24, however, it is verified that the renewal documents were previously submitted and is pending to be processed by the Administrator Certification Bureau. Staff have current CPR & First Aid certification.
There are no deficiencies issued today. An exit interview was held and a copy of this report was given to the
administrator.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2024
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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