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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306090073
Report Date: 07/21/2022
Date Signed: 07/21/2022 05:40:30 PM

Document Has Been Signed on 07/21/2022 05:40 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ARROW HOUSE, THEFACILITY NUMBER:
306090073
ADMINISTRATOR:JOHN LIEBERMANFACILITY TYPE:
730
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 20CENSUS: 5DATE:
07/21/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:John Lieberman, Facility Administrator TIME COMPLETED:
03:45 PM
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On July 21, 2022, at 11:15 AM, Licensing Program Analyst (LPA) Charmaine Linley arrived at the facility to continue a Comprehensive Annual Post-Licensing Inspection visit that began on 07/20/2022. LPA met with John Lieberman, Facility Administrator. During the inspection, LPA reviewed staff files and client files.


All the staff files are stored and secured electronically at the corporate office. LPA reviewed ten out of twenty staff files (see confidential name list, LIC811, dated 07/21/2022) via Zoom with Human Resources Director, Jennifer Richardson from 9:00 am-10:15 am. All staff that works at the facility have Department of Justice, FBI, and Child Abuse Index Clearances. LPA reviewed staff training records. During the inspection, LPA interviewed three out of five staff.

LPA reviewed four out of five client files (C1-C4) (see confidential names list, LIC 811, dated 07/20/2022). LPA was unable to conduct interviews, due to clients attending group sessions. The client files are maintained in a locked cabinet in the medication room.

LPA completed the component III Orientation and discussed Incident reporting, including incidents related to Assembly Bill 388 law enforcement contacts as well as incidents involving emergency interventions. The facility was informed that the address to this facility is available to the public. All special incident reports (SIRs) will be sent via e-mail to: cclpaccr@dss.ca.gov. The reporting requirements were reviewed with the Facility Administrator on this date. Please complete the LIC 500 and send it to LPA Linley within 30 days.

Based on the facility’s post-licensing inspection review, two deficiencies were issued for CCR 84070(b)(13) and CCR 80075(k)(7)(B)
SUPERVISORS NAME: Ann Valenzuela
LICENSING EVALUATOR NAME: Charmaine Linley
LICENSING EVALUATOR SIGNATURE: DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2022
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 07/21/2022 05:40 PM - It Cannot Be Edited


Created By: Charmaine Linley On 07/21/2022 at 02:23 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: ARROW HOUSE, THE
FACILITY NUMBER: 306090073

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
84070(b)(13)
Children's Records
(b) The following information regarding the child shall be obtained and maintained in the child's record: (13) A separate log for each psychotropic medication prescribed to the child documenting all the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in four out of four clients (C1, C2, C3, C4), medication sheets, which did not have a separate log for each psychotropic medication prescribed to the child, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/29/2022
Plan of Correction
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Administrator will ensure a separate log for each Psychotropic Medication is kept and reflects required documentation. Administrator will provide a copy of C1-C4's separate logs with each psychotropic medication to LPA via email by 07/29/20222 at 5:00pm.
Type B
Section Cited
CCR
80075(k)(7)(B)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following: (B) The name of the prescribing physician.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in four out of four (C1, C2, C3, C4) Centrally Stored Medication Records, which did not list the facility license number, administrator, start date, and prescribing physician, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/29/2022
Plan of Correction
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Administrator will ensure all four clients have their Centrally Stored Medication Records updated to reflect the required documentation of the facility license number, administrator name, start date, and prescribing physician and send copies to the LPA by 07/29/2022 at 5:00pm.
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:Ann Valenzuela
LICENSING EVALUATOR NAME:Charmaine Linley
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2022


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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ARROW HOUSE, THE
FACILITY NUMBER: 306090073
VISIT DATE: 07/21/2022
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An exit interview was conducted, and a copy of this report and appeals were discussed with John Lieberman, Facility Administrator. Due to printer malfunction, LPA will email a copy of the the LIC 809, LIC 809D, LIC 811, and appeals form, to John Lieberman, Facility Administrator. A copy of the report will be placed in the facility file.
SUPERVISORS NAME: Ann Valenzuela
LICENSING EVALUATOR NAME: Charmaine Linley
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022
LIC809 (FAS) - (06/04)
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