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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005512
Report Date: 10/30/2024
Date Signed: 10/30/2024 02:32:44 PM

Document Has Been Signed on 10/30/2024 02:32 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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:BARN LIFEFACILITY NUMBER:
306005512
ADMINISTRATOR/
DIRECTOR:		CARVER, MATHEW WILLIAMFACILITY TYPE:
775
ADDRESS:126 E 16TH STTELEPHONE:
(800) 759-1930
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY: 30CENSUS: 20DATE:
10/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:09 PM
MET WITH:Alyssa Panis - Chief Operations OfficerTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dwayne Mason Jr. conducted an unannounced annual required visit. LPA arrived at the facility and was greeted by Administrative Assistant Julie Joyce. LPA met with Chief Operations Officer Alyssa Panis (COO) and explained the nature of the visit.

The facility is made up of one-story buildings. The facility houses staff offices, clinical offices, a library, a reception area, three bathrooms, a courtyard and a renovated barn for group therapy.

LPA observed the facility has activity supplies for client use including exercise equipment, books, musical instruments, games, computers and more. The facility also has art on the walls, access to computers for virtual appointments and dogs that live on the facility premises as well. The facility does not store or provide food. Clients maintain their own medication and finances. LPA observed the facility's infection control plan and disaster plan to be completed. Water in bathrooms measured between 105-120 degrees Fahrenheit. LPA observed fire extinguishers were last serviced on 4/8/2024 as indicated by the attached service tags. The sprinkler/smoke detectors are scheduled to be serviced on 11/5/2024. LPA verified this via an email confirmation received by the COO. LPA observed clients in group therapy and individual therapy. LPA reviewed employee and resident files. Based on record review and interview with staff, LPA determined the facility does not have medical assessments on file for some clients. A deficiency is being issued.

Based on the observations made during today’s visit, one deficiency is being issued per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with facility staff and a copy was provided as well.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2024
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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Document Has Been Signed on 10/30/2024 02:32 PM - It Cannot Be Edited


Created By: Dwayne L Mason On 10/30/2024 at 02:13 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BARN LIFE
FACILITY NUMBER: 306005512

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82069(a)
Client Medical Assessments
(a) Prior to or within 30 calendar days following the acceptance of a client, the licensee shall obtain a written medical assessment of the client that determines the licensee's ability to provide necessary health-related services to the client. The assessment shall be used in developing the Needs and Services Plan.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above due to at least two client files not having a medical assessment in them. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/08/2024
Plan of Correction
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Facility staff stated they will acquire medical assessments for all clients who will have been at the facility for at least 30 days by the POC due date (11/8/2024). Facility staff stated they will email LPA the medical assessments by Close of Business day (COB) 11/8/2024.
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:Armando J Lucero
LICENSING EVALUATOR NAME:Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2024


LIC809 (FAS) - (06/04)
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