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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603484
Report Date: 08/24/2023
Date Signed: 08/24/2023 12:19:40 PM

Document Has Been Signed on 08/24/2023 12:19 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:CANYON RIMFACILITY NUMBER:
198603484
ADMINISTRATOR:EVE, AUCIONE COELHOFACILITY TYPE:
735
ADDRESS:6512 BEQUETTE AVETELEPHONE:
(562) 395-8118
CITY:PICO RIVERASTATE: CAZIP CODE:
90660
CAPACITY: 4CENSUS: 4DATE:
08/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Aucione Eve and Leslie Eve- Licensees/AdministratorsTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) V. Maldonado made an unannounced complaint visit at the facility for the purpose of conducting the annual inspection, using the Care Compliance and Regulatory Enforcement (CARE) Tool to evaluate the facility. Upon arrival, LPA knocked on the door several times and called the facility telephone number. There was no answer. LPA phoned Licensee Aucione Eve directly and informed her of the visit. She stated she would come over right away and arrived shortly after with Leslie Eve to assist with the visit. The facility is licensed to serve adult clients, ages 18-59, and is approved for (4) ambulatory clients, only.

The facility is a single-story home, located in a residential area. The home consists of a living room, (2) client bedrooms, (1) isolation/COVID-19 room with bathroom, (1) client bathroom, a kitchen, dining room, attached garage, and shaded patio with seating in the back yard.
The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical and Dental, Disaster Preparedness, and Emergency Intervention.

During today's visit, LPA Maldonado obtained a copy of the client and staff roster, and conducted a tour of the physical plant with assistance of Licensee. The following was observed:
  • One central entry point for universal entry screening
  • Mitigation Plan and Infection Control Plan approved and in place
  • Sufficient PPE stored for 30-days and readily available for use, throughout the home and stored in the garage
  • Physical plant inside and outside is clean, sanitary and in good repair
  • All walkways and pathways observed to be free of obstruction/hazards

(Report Continued on LIC809-C...)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2023
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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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: CANYON RIM
FACILITY NUMBER: 198603484
VISIT DATE: 08/24/2023
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  • All rooms inspected had the required furniture, bedding, linens, chair, adequate lighting, & closet space
  • Each restroom is equipped with a toilet, shower, and wash basin
  • All kitchen and laundry equipment were clean and operational
  • Water tested and measured at 108.6*F, which is in compliance
  • Food was inspected and was sufficient for clients in care. Requirement met for 2-day perishables and 7-day non-perishables available
  • One refrigerator inside the home and another freezer in the garage observed fully stocked with a variety of nutritious foods
  • Kitchen cabinets and garage were observed with a variety of non-perishables including vegetables, proteins, cereals
  • Emergency disaster plan, personal rights and complaint procedures are posted
  • First Aid Kit has required items and First Aid Manual is available
  • Smoke/Carbon monoxide detectors were tested and operating properly
  • Fire extinguisher observed in the kitchen with a current inspections and fully charged
  • Working telephone for clients to use
  • No bodies of water located on the premises
  • Adequate seating in common areas for licensed capacity
  • Cleaning supplies/toxins are stored in a locked under the kitchen sink, inaccessible to clients
  • Sharps are stored in a kitchen cabinet, locked and inaccessible to clients
  • (4) Client Files reviewed and observed to be complete with/but not limited to- current health screenings, appraisals, admission's agreements, personal rights, and emergency contact information
  • (2) Staff files were reviewed and were complete with/but not limited to- fingerprint clearances, health screenings, and proof of required annual training
  • (3) Resident medications were reviewed and observed to be administered as prescribed and documented properly. (1) client is not on any medications- medications were not reviewed
  • (2) Staff were interviewed
  • (0) client interviews were conducted due to clients being at Day Program during the visit


Per California Code of Regulations, Title 22, no deficiencies were observed or cited during today's visit.
An exit interview was conducted with Licensees Aucione and Leslie Eve, and a copy of this report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
LIC809 (FAS) - (06/04)
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