198601553-10-2-2025-28-AS-BPEA-DM3VN2-20251002163425

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601553
Report Date: 10/02/2025
Date Signed: 10/02/2025 04:35:08 PM

Document Has Been Signed on 10/02/2025 04:35 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 HOME		FACILITY NUMBER:	198601553
ADMINISTRATOR/ DIRECTOR:	CHRIS SCHLANSER		FACILITY TYPE:	734
ADDRESS:	23612 MEADCLIFF PLACE		TELEPHONE:	(909) 274-7620
CITY:	DIAMOND BAR	STATE: CA	ZIP CODE:	91765
CAPACITY: 5		CENSUS: 5	DATE:	10/02/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:05 PM
MET WITH:	Efnan Scott - Administrator		TIME VISIT/ INSPECTION COMPLETED:	05:00 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 Analysts (LPAs) Bennette Pena and Gabriela Castro conducted an unannounced Required- 1 year visit. LPAs were met by Efnan Scott, Administrator and explained the purpose of the visit. This facility is licensed as an Adult cliential Facility for Persons with Special Healthcare Needs (ARFPSHN) and is vendored by the San Gabriel/Pomona Regional Center. The facility is approved to serve (5) developmentally disabled clients ages 18 and above, (5) clients may be bedridden. LPAs utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Facility has one (1) person capable and responsible for communicating with emergency personnel in the facility at all times. Contact information of each clients' medical and mental health providers, including emergency agency are current. Physical Plant/Environment Safety: The facility is a single story home located in a cliential neighborhood which consists of (5) client bedrooms, (2) bathrooms, staff office, 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 every 2 weeks. Operational Requirements: A fire clearance is in place. Facility has doctor's authorization for use of half bed rails. Staff are adhering to operational requirements. Health and Safety Code Statutes adhered to as well. Emergency drills are being conducted as required. Facility maintains and operates automated external defibrillator (AED) and meets the requirements. LPAs also reviewed the P&I ledger for the clients. Surety bond is valid in the amount of $2000.***REPORT CONTINUED ON LIC809-C***

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CALIFORNIA MENTOR - MEADCLIFF HOME	FACILITY NUMBER: 198601553
	VISIT DATE: 10/02/2025

NARRATIVE

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Personnel Records-Training: Three (3) staff files were reviewed for criminal background clearance and training. Personnel records have health/TB screenings. Current Administrator's certificate is pending, expires on 07/25/2026.
Client Records-Incident Reports: Four (4) client files were reviewed containing face sheet, admission agreements, Physician's Report, Medical/Functional assessments, TB clearance, Personal rights, Medical Consent, current IPP report, and Property valuables form. (1) out of (5) clients is under hospice care but no hospice waiver approved.
Client Rights-Information: client personal rights are posted. Visiting policy is posted at a location that is visible and accessible to clients and families. Facility provides internet services to all clients and have access to the facility phone.
Food Service: The kitchen was inspected and did not have sufficient supply of 2-day perishable & 7-day non-perishable food. Pesticides and cleaning supplies are kept away from the food preparation areas.
Health Related Services: (3) clients' medications were reviewed during the visit and did not observe any deficiencies. The facility uses the Point Click Care (PCC) log to document medications given. Medications are stored in a cart and also in the locked storage space. First-aid supplies along with a manual and Automated External Defibrillator (AED) are maintained in the facility.
Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan containing emergency evacuation, storage and preservation of medications, operation of manual assist devices. The facility conducts emergency drill at least every (6) months. Last fire drill was conducted in 06/24/2025.

Deficiency cited and Technical violation issued. Exit interview and a copy of this report along with the appeal rights were provided to the Administrator, Efnan Scott.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/02/2025 04:35 PM - It Cannot Be Edited

Created By: Bennette Pena On 10/02/2025 at 04:03 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: 10/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85075.2(a)

85075.2 Facility Hospice Care Waiver.....(a) In order to accept or retain terminally ill clients and permit them to receive care from hospice, the licensee shall have requested in writing and been granted a Facility Hospice Care Waiver from the Department. The licensee’s written request shall include, but not be limited to, the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the Administrator did not comply with the section cited above in which (1) out of (5) residents is under hospice care but no waiver granted by Licensing which poses/posed a potential health, safety or personal rights risk to clients in care.
	POC Due Date: 10/16/2025
	Plan of Correction
1 2 3 4	Administrator agreed to send the waiver request along with the documents required for hospice waiver to CCL/LPA by POC due date.

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.

	David Sicairos
NAME OF LICENSING PROGRAM MANAGER:

	Bennette Pena
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2025

LIC809 (FAS) - (06/04)

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