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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601553
Report Date: 11/29/2021
Date Signed: 11/29/2021 11:58:38 AM

Document Has Been Signed on 11/29/2021 11:58 AM - 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: 4DATE:
11/29/2021
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Cristal Parra, lead caregiverTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Nicole Spencer conducted a Case Management - Annual Continuation visit. LPA Spencer was greeted by lead caregiver Cristal Parra and explained the purpose of today's visit. The initial annual visit was conducted on 11/24/21. During the initial visit, the entire physical plant was toured. During today's visit on 11/29/21, staff files, client files, and medications were reviewed.
The following was observed/inspected:
  • The facility had a universal entrance screening area; sign-in log, screening logs, and temperature logs were maintained.
  • COVID-19 signage was placed in several areas of the facility including the front entrance.
  • On 11/24/21, there was a sufficient 2-day supply of perishable foods but an insufficient 7-day supply of non-perishables as there were no canned fruits. On 11/29/21, a sufficient supply was observed.
  • All areas were found to be clean and in good repair.
  • On 11/24/21, LPA observed that cleaning solutions and sharp knives were placed in an unlocked cabinet. A staff member immediately locked it.
  • Each room contained required furniture including bed, dresser, night stand, lamp, chair, and closet.
  • All beds contained the required linens including mattress cover, fitted sheet, flat sheet, blanket, and comforter.
  • Hot water temperature was measured and was not within the required 105-120 degrees F. On 11/24/21, hot water temperature measured between 81.3-96.5. On 11/29/21, hot water temperature measured between 124-131 degrees F.
  • Facility maintained a 30-day supply of PPE to include masks, gowns, and face shields.
  • Smoke detectors/carbon monoxide detectors were present and operable.
  • Oxygen tanks were observed to be secured on stands.
  • A fire extinguisher was observed to be fully charged and last serviced in June 2021.
  • Medications were given as prescribed by the physician. Facility maintained 30-day supply of meds.
***Continued on LIC809C***
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: LaJean Nicole Spencer
LICENSING EVALUATOR SIGNATURE: DATE: 11/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2021
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 11/29/2021 11:58 AM - It Cannot Be Edited


Created By: LaJean Nicole Spencer On 11/29/2021 at 11:13 AM
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: 11/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/30/2021
Section Cited
CCR
80088(e)(1)

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80088(e)(1) Furniture, fixtures, equipment, and supplies:Hot water temperature controls shall be maintained...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 was not met as evidenced by...
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The administrator stated that he will have the water meter adjusted by POC due date. In addition, staff will maintain a temperature log to test the temperature twice a day for the next 7 days and submit log to CCL.
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Based on observation, the licensee did not ensure that hot water temperature was maintained between 105-120 degrees F. On 11/24/21, hot water temperatures were below 105 degrees. On 11/29/21, hot water temperatures were above 120 degrees. This poses an immediate safety hazard to clients.
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Type A
11/24/2021
Section Cited
CCR80087(g)

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80087(g) Buildings and grounds: Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement was not met as evidenced by...
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The staff member immediately locked the area where cleaning solutions and sharp knives were located.

Corrected by visit.
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Based on observation on 11/24/21, the licensee did not ensure that cleaning solutions and sharp knives were stored in a locked cabinet. This poses an immediate safety hazard to clients in care.
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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:Christine Yee
LICENSING EVALUATOR NAME:LaJean Nicole Spencer
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/29/2021 11:58 AM - It Cannot Be Edited


Created By: LaJean Nicole Spencer On 11/29/2021 at 11:27 AM
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: 11/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/30/2021
Section Cited
CCR
80075(f)

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80075(f) Health-Related Services: Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross. This requirement was not met as evidenced by...
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The administrator stated that he will provide proof of CPR/first aid card for staff #1 and send to CCL by POC due date.
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Based on record reviews, the licensee did not ensure that an updated first aid/CPR card was present in the file for 1 out of 5 staff files inspected. This poses a potential health risk to clients in care.
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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:Christine Yee
LICENSING EVALUATOR NAME:LaJean Nicole Spencer
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2021


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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CALIFORNIA MENTOR - MEADCLIFF HOME
FACILITY NUMBER: 198601553
VISIT DATE: 11/29/2021
NARRATIVE
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  • All client files were inspected; contact information and health assessments were up-to-date.
  • Five (5) staff files were inspected; One (1) out of four (4) staff was missing first-aid/CPR card.
  • The Administrator's certificate expired on 9/2021; however, administrator provided proof that renewal was already submitted and is awaiting certificate in the mail.



Pursuant to Title 22, deficiencies were cited on the attached 809D. An exit interview was conducted, appeal rights provided, and a copy of this report was emailed to the administrator.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: LaJean Nicole Spencer
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2021
LIC809 (FAS) - (06/04)
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