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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005573
Report Date: 03/15/2024
Date Signed: 03/15/2024 11:04:07 AM

Document Has Been Signed on 03/15/2024 11:04 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:UNITED PEACE RESIDENTIAL HOMES 2FACILITY NUMBER:
306005573
ADMINISTRATOR:TA-PEREZ, MICHELEFACILITY TYPE:
735
ADDRESS:12792 ARLETTA CIRTELEPHONE:
(657) 251-0030
CITY:GARDEN GROVESTATE: CAZIP CODE:
92840
CAPACITY: 4CENSUS: 4DATE:
03/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Zoe Ta-PerezTIME COMPLETED:
11:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA was greeted and granted entry by Staff Zoe Ta-Perez and explained the purpose of the inspection. During the inspection LPA and Staff Ta-Perez conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, garage and observed the following:

This is a one-story home with four bedrooms, two bathrooms, and attached two-car garage. All client bedrooms had the required furnishings. LPA observed all client beds had linens and blankets. LPA observed all windows were screened. LPA did not observe a shaded sitting area in any of the facility's outdoor areas; a Technical Violation was issued on today’s date. LPA did not observe any clients present, as they were away at day program. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested at 112.8 F degrees. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. Food menu was also posted and visible. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged with service tag dated February 15, 2024. Gas stove, microwave, washer, and dryer were all inspected. Sharps were observed locked in a kitchen drawer. All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients. Medication cabinet was observed to be locked. Upon physical review of client medications, LPA observed three out of four were not in their original containers and had been pre-prepared a week in advanced in a weekly medication organizer or added to pre-package bubble pack medication; a Deficiency was issued on today’s date. LPA reviewed four client files and two staff files. Clients were not present to be interviewed. LPA interviewed staff present.

Based on the observations made during today’s inspection, one deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/15/2024
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 03/15/2024 11:04 AM - It Cannot Be Edited


Created By: Claudia Gutierrez On 03/15/2024 at 10:38 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: UNITED PEACE RESIDENTIAL HOMES 2
FACILITY NUMBER: 306005573

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(k)(5)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (5) Each client's medication shall be stored in its originally received container.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and staff interview, the licensee did not comply with the section cited above in three out of four client medications which poses a potential health and safety risk to persons in care.
POC Due Date: 04/15/2024
Plan of Correction
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Staff Ta-Perez stated all client medication would be kept in its original container. Licensee will provide staff training to ensure centrally stored medication meets regulation requirements. LPA will conduct an additional visit to ensure centrally stored medication meets regulation requirements and staff training has been conducted.
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:Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2024


LIC809 (FAS) - (06/04)
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