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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 330909355
Report Date: 09/06/2024
Date Signed: 09/06/2024 01:14:20 PM

Document Has Been Signed on 09/06/2024 01:14 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:PEPPERMINT RIDGE - CYPRESS POINTFACILITY NUMBER:
330909355
ADMINISTRATOR/
DIRECTOR:		TERRAY DOTYFACILITY TYPE:
735
ADDRESS:632 MAGNOLIA AVENUETELEPHONE:
(951) 273-7342
CITY:CORONASTATE: CAZIP CODE:
92879
CAPACITY: 6CENSUS: 6DATE:
09/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Jessica Paz and Terray Doty, AdministratorsTIME VISIT/
INSPECTION COMPLETED:
01:20 PM
NARRATIVE
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On 09/06/2024 at 08:50 AM, Licensing Program Analysts (LPAs) Melody Brown and Eldin Serrano conducted an unannounced visit to the facility to conduct the required comprehensive annual inspection. LPAs Brown and Serrano were greeted by Administrator Jessica Paz and gained access at the home. LPAs Brown and Serrano explained the purpose of the visit to Administrator Paz .

The facility has five (5) bedrooms, two (2) bathrooms, kitchen, dining room, living room, attached garage, and backyard. The facility is vendorized by Inland Regional Center (IRC). LPAs Brown and Serrano completed a walkthrough of the facility, review of records, Personal and Incidental (P&I) and medications audit.



Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD), LPAs Brown and Serrano observed no clients during the visit. There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 76 degrees Fahrenheit. LPAs Brown and Serrano inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, chairs. However, LPAs observe client 1 (C1), Client 3 ( C3), client 4 (C4), client 6 (C6) do not have lights in their bedrooms also C6 does not have a lamp in C6 room. Technical violation issued.. LPAs Brown and Serrano inspected client bathrooms; bathrooms were clean, and appliances were found functional. Water temperatures tested at 105 degrees Fahrenheit. The facility is equipped with operational smoke detectors and carbon monoxide detectors, charged fire extinguishers, and first aid kit with first aid book. In addition, LPAs Brown and Serrano observed non slip mat in clients bathroom.

Posters such as the personal rights, CCLD complaint poster, and emergency disaster plan were posted in a common area. Client medications were kept in secure cabinets inaccessible to clients.
*** Continuation in LIC809C ***
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: PEPPERMINT RIDGE - CYPRESS POINT
FACILITY NUMBER: 330909355
VISIT DATE: 09/06/2024
NARRATIVE
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The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility. Moreover, LPAs observed no night lights maintained in hallways and passages to non private bathrooms. Deficiency will be issued.

Yards/Outside: One shaded patio, one (1) side gate with self-latching handle on the left side of the house that leads into the backyard, attached two (2) car garage observed. All outdoor pathways were free of obstructions.

Food Service: LPAs Brown and Serrano observed two (2) day(s) supply of perishable food and seven (7) day(s) supply of non-perishables food and snacks. Dishes, cups, and utensils were stored properly.


Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPAs Brown and Serrano reviewed four (4) client files for admission agreements, medical assessments/physician reports, and Individual Program Plan (IPP) and centrally stored medication list. LPAs Brown and Serrano observed files reviewed were complete. LPAs Brown and Serrano also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test result. LPAs Brown and Serrano observed Staff 3 (S3) and staff 5 (S5) working at the facility with criminal background clearance but their criminal background clearance were not transferred to the facility prior to employment. Deficiency will be issued and civil penalty of $500.00 per individual will be assessed today. In addition, LPAs observed staff 3 (S3) did not complete the required tuberculosis (TB) test. Deficiency will be issued.

LPAs Brown and Serrano audited four (4) clients’ medications and no issues were observed. LPAs Brown and Serrano audited four (4) client's Personal and Incidental (P&I) and no issues observed.

Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809D, LIC9102TV. and Appeal Rights were discussed, and copies were provided to Administrators Jessica Paz and Terray Doty.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 09/06/2024 01:14 PM - It Cannot Be Edited


Created By: Melody Brown On 09/06/2024 at 12:22 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
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: PEPPERMINT RIDGE - CYPRESS POINT
FACILITY NUMBER: 330909355

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, (interview and record review), the licensee did not comply with the section cited above by not ensuring that staff 3 (S3) complete the required Tuberculosis (TB) test as evidenced of no completed TB test in S3 file which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/07/2024
Plan of Correction
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Licensee stated to submit tS3 TB test with result to LPA Brown on plan of correction (POC) due date.
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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 09/06/2024 01:14 PM - It Cannot Be Edited


Created By: Melody Brown On 09/06/2024 at 12:22 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
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: PEPPERMINT RIDGE - CYPRESS POINT
FACILITY NUMBER: 330909355

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(e)(2)
Fixtures, Furniture, Equipment, and Supplies
(e) Emergency lighting, which shall include at a minimum working flashlights or other battery-powered lighting, shall be maintained and readily available in areas accessible to clients and staff. (2) Night lights shall be maintained in hallways and passages to nonprivate bathrooms.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Night lights are maintained in hallways and passages to non private bathrooms which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/16/2024
Plan of Correction
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Licenseee stated to obtain or purchase the required night lights and submit proof to LPA Brown on plan of correction (POC) due date.
Type B
Section Cited
CCR
80019(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 80019(f) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not transferring staff 3 (S3) and staff 5(S5) criminal record clearance to the facility prior to employment which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/16/2024
Plan of Correction
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LIcensee transferred S3 and S5 crimal record clearance to the facility during the visit today. POC cleared.
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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2024


LIC809 (FAS) - (06/04)
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