330910554-6-10-2022-18-AS-JGAR-CF9U82-20220610152049

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 330910554
Report Date: 06/10/2022
Date Signed: 06/10/2022 03:21:30 PM

Document Has Been Signed on 06/10/2022 03:21 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
RIVERSIDE, CA 92507

FACILITY NAME:	PARADISE GUEST RANCH		FACILITY NUMBER:	330910554
ADMINISTRATOR:	VASQUEZ, CONNIE		FACILITY TYPE:	740
ADDRESS:	19150 KRIS ROAD		TELEPHONE:	(760) 329-8905
CITY:	SKY VALLEY	STATE: CA	ZIP CODE:	92241
CAPACITY:	6	CENSUS: 2	DATE:	06/10/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:57 PM
MET WITH:	Aide Espinoza, Caretaker		TIME COMPLETED:	03:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Jesse Gardner made an unannounced visit to conduct an annual inspection, with emphasis on infection control. LPA was greeted by Caretaker Aide Espinoza and explained the purpose of today's visit. There were 2 clients inside the facility at the time of visit. Administrator Connie Vasquez later arrived at the facility. During today’s visit, LPA toured the facility and made observations pertaining to the facility’s infection control measures. LPA observed proper signage throughout the facility, sufficient hand hygiene supplies, and sufficient cleaning and disinfecting provisions. LPA noted the absence of a 30 days supply of Personal Protective Equipment (PPE) for residents, and Licensee agreed to replenish the supply. A Technical Assistance (TA) LIC9102 was issued. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in overall infection control. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and residents for COVID-19. When and how to isolate/quarantine clients, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas. The facility also has a plan in place to monitor clients regularly for any changes in condition and to subsequently notify the client's physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses. Continued on LIC809-C

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Jesse Gardner	TELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022

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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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
RIVERSIDE, CA 92507

FACILITY NAME: PARADISE GUEST RANCH	FACILITY NUMBER: 330910554
	VISIT DATE: 06/10/2022

NARRATIVE

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During the tour of the facility, LPA observed the following violations of Title 22:

1. Medications not kept in their prescribed containers
2. Video camera's are in all private bedrooms
3. Non-background cleared Caretaker alone in the facility (Administrator qualifications and duties)

For the aforementioned violations, Type B citations were issued.

Upon review of staff roster, LPA found that Caretaker Aide Espinoza (S1) not to be fingerprinted with DOJ and working inside the facility. S1 indicated that they assist with the administer of medications, and have been employed for approximately 1 month. When asked, S1 stated that they did not have time to complete the background process.

Thus, an immediate $500 Civil Penalty was issued.

An exit interview was conducted, and a copy of this report was discussed with and provided to Ms. Vasquez along with a copy of the LIC811, LIC421BG, LIC809-D and Appeal Rights.

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Jesse Gardner	TELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/10/2022 03:21 PM - It Cannot Be Edited

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
RIVERSIDE, CA 92507

FACILITY NAME: PARADISE GUEST RANCH	FACILITY NUMBER: 330910554
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(1)

87355 CRIMINAL RECORD CLEARANCE: (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing, or volunteering in a licensed facility. (1) Obtain a California clearance or a criminal record exemption as required by the Department. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA record review of staff roster, S1 did not have a clearance. Thus, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/11/2022
	Plan of Correction
1 2 3 4	Licensee agrees to self certify they understand and will comply with the regulation and provide proof of understanding by submitting an email to LPA by POC date. LPA observed S1 leave the facility during the visit.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Jesse Gardner	TELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/10/2022 03:21 PM - It Cannot Be Edited

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
RIVERSIDE, CA 92507

FACILITY NAME: PARADISE GUEST RANCH	FACILITY NUMBER: 330910554
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Request Denied

Type B

Section Cited

CCR

87468.2(a)(1)

87468.2 ADDITIONAL PERSONAL RIGHTS OF RESIDENTS IN PRIVATELY OPERATED FACILITIES: (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (1) To have a resonable level of personal privacy in accommodations.. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation of video camera's in resident bedrooms, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/24/2022
	Plan of Correction
1 2 3 4	Licensee agrees to immediately remove the camera's from resident rooms and show proof of that to LPA, as well as provide a written understanding of the regulation cited by POC date.

Type B

Section Cited

CCR

87465(h)(5)

87465 INCIDENTAL MEDICAL AND DENTAL CARE: (h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation of medications in paper cups stored in the kitchen with other medication, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/24/2022
	Plan of Correction
1 2 3 4	Licensee agrees to discontinue transferring medications outside of the originally prescribed container. Licensee further agrees to self-certify to LPA that they understand the regulation by submitting a memorandum of understanding to LPA by POC date.

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: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Jesse Gardner	TELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 06/10/2022 03:21 PM - It Cannot Be Edited

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
RIVERSIDE, CA 92507

FACILITY NAME: PARADISE GUEST RANCH	FACILITY NUMBER: 330910554
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87405(a)

87405 ADMINISTRATOR - QUALIFICATIONS AND DUTIES: (a) All facilities shall have a qualified and currently certified administrator...When the Administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section.. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation of S1 alone in the facility upon entry without a background clearance, and that S1 has been around residents for 1 month, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/24/2022
	Plan of Correction
1 2 3 4	Licensee to self certify that they understand the regulation cited above and agrees to submit a memorandum of understanding of the regulation by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Jesse Gardner	TELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022

LIC809 (FAS) - (06/04)

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