<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800085
Report Date: 12/03/2024
Date Signed: 12/03/2024 06:58:24 PM

Document Has Been Signed on 12/03/2024 06:58 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:MCCOY ADULT GROUP HOMEFACILITY NUMBER:
331800085
ADMINISTRATOR/
DIRECTOR:		LACY,TORIFACILITY TYPE:
735
ADDRESS:1113 GARRETSON AVETELEPHONE:
(909) 437-5262
CITY:CORONASTATE: CAZIP CODE:
92879
CAPACITY: 6CENSUS: 4DATE:
12/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Licensee/Chief Executive Officer Charisse McCoy TIME VISIT/
INSPECTION COMPLETED:
07:00 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
On 12/03/2024 at 01:00 PM, Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility to complete the required comprehensive annual inspection to the facility. LPA Brown was greeted by Licensee/Chief Executive Officer (CEO) Charisse McCoy and gained access at the home. LPA Brown explained the purpose of the visit to Licensee/CEO McCoy.

The facility is a four (4) bedroom, three (3) bathroom home with a kitchen/dining area, and living room, a garage and an apartment unit. The facility is an Adult Residential Facility (ARF) level 4i home vendorized by Inland Regional Center (IRC). The facility is licensed for a capacity of six (6) clients and the current census is four (4) clients. LPA Brown was accompanied by Staff #2 (S2) to conduct a general overall inspection, review of records, and Personal and Incidental (P&I) audit and medications audit which included, but was not limited to, the following:



Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD), LPA Brown observed three (3) clients during the visit. One (1) clients’ out in the community. There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 74 degrees Fahrenheit. LPA Brown inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs, and sufficient lighting. LPA Brown inspected client bathrooms; bathrooms were clean, and appliances were found functional. Water temperature tested at 133.3 degrees Fahrenheit. Deficiency will be issued. The facility is equipped with operational smoke detectors, carbon monoxide detectors, charged fire extinguisher, and first aid kit with first aid book.

Posters such as; the personal rights, CCLD complaint poster, labor laws, and emergency disaster plan were posted in a common area. Client medications were kept in secure cabinets inaccessible to clients. LPA Brown observed night lights at the hallway leading to clients' shared bathrooms. The facility had emergency kits, but LPA Brown observed expired emergency food and and no emergency water.* Continuation in LIC809C *
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2024
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 7
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: MCCOY ADULT GROUP HOME
FACILITY NUMBER: 331800085
VISIT DATE: 12/03/2024
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
26
27
28
29
30
31
32
Deficiency will be issued. There are no firearms and ammunition in the facility. In addition, LPA Brown observed one (1) bleach spray on top of the kitchen sink, not locked and accessible to clients in care. Deficiency will be issued. Moreover, during the tour of the facility, LPA Brown obtained information that Tenant #1 (T1) lives on the apartment unit on top of the garage since 2023 and per documents review, T1 does not have criminal background clearance. Deficiency will be issued and civil penalty of $500.00 will be assessed today, 12/03/2024 and will continue to be assessed of $100.00/day until corrected.

Yards/Outside: Two (2) shaded patio, one (1) gate with self-latching handle in front of the house, detached two (2) car garage observed and an apartment unit on top. All outdoor pathways were free of obstructions.

Food Service: LPA Brown 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: LPA Brown observed no Infection Control Plan developed by the Licensee at the facility. Deficiency will be issued. LPA Brown reviewed two (2) client files for admission agreements, medical assessments/physician reports, Individual Program Plan (IPP) and Centrally Stored Medication List. LPA Brown observed that Client #2 (C2) does not have a completed Admission Agreement maintained in C2 file. Deficiency will be issued. Also, LPA Brown observed no Restricted Health Care Plan in place for Client #1 (1) maintained in C1 file. Deficiency will be issued. LPA Brown also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test result. LPA Brown observed that Staff #3 (S3) has criminal background clearance but the Licensee did not transfer S3 criminal record clearance to the facility prior to employment on 09/2024. Deficiency will be issued and civil penalty of $500.00 will be issued today, 12/03/2024 and will continue to be assessed of $100.00/day until corrected. Furthermore, LPA Brown observed Staff #3 (S3) does not have the required Emergency Intervention Training/CPI in S3 file. Deficiency will be issued. LPA Brown audited two (2) clients’ medications and no issues were observed. LPA Brown audited two (2) client's P&I and no issue observed.

Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809D,LIC421BG and Appeal Rights were discussed, and copies were provided to Licensee/Chief Executive Officer Charisse McCoy.

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

DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 12/03/2024 06:58 PM - It Cannot Be Edited


Created By: Melody Brown On 12/03/2024 at 04:58 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: MCCOY ADULT GROUP HOME
FACILITY NUMBER: 331800085

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(2)
80019 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: (2) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Tenant #1 (T1) who's an adult individual residing on top of the garage has criminal background clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/04/2024
Plan of Correction
1
2
3
4
Licensee stated to obtain T1 criminal background clearance and submit proof to LPA Brown on Plan of Correction (POC) due date.
Deficiency Dismissed
Type A
Section Cited
CCR
80087(g)
80087 Buildings and Grounds (g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that the one (1) bottle of clorox spray observed on top of the kitchen sink was locked and not accessible to clients in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/04/2024
Plan of Correction
1
2
3
4
Licensee stated to train all staff on CCR 80087(g) and submit proof to LPA Brown on Plan of Correction (POC) due 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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2024


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 12/03/2024 06:58 PM - It Cannot Be Edited


Created By: Melody Brown On 12/03/2024 at 05:56 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: MCCOY ADULT GROUP HOME
FACILITY NUMBER: 331800085

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
80092.1(a)
General Requirements for Restricted Health Conditions
(a) A client with a restricted health condition specified in Section 80092 may be admitted or retained in an adult CCF if all requirements in Sections 80092.1(b) through (o) are met.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that there's a restricted health care plan in place for Cleint #1 (C1) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/04/2024
Plan of Correction
1
2
3
4
Licensee stated to submit copy of C1 Restricted Health Care Plan to LPA Brown on Plan of Correction (POC) due date..
Type A
Section Cited
CCR
80088(e)(1)
CCR 80088 Fixtures, Furniture, Equipment, and Supplies (e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:



This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that the hot water temperature was maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C) as evidenced of hot water measured at 133.3 degrees Fahrenhet which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/04/2024
Plan of Correction
1
2
3
4
LIcensee stated to regulate the hot water in clients shared bathroom to not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C) and submit proof to LPA Brown on Plan of Correction (POC) due 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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2024


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 12/03/2024 06:58 PM - It Cannot Be Edited


Created By: Melody Brown On 12/03/2024 at 05:56 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: MCCOY ADULT GROUP HOME
FACILITY NUMBER: 331800085

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type B
Section Cited
CCR
85095.5(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022. 

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not developing the Infection Control Plan as required for the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2024
Plan of Correction
1
2
3
4
Licensee stated to develop the required Infection Control Plan and submit a copy 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
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Staff #3 (S3) criminal background clearance was transferred at the facility prior to employment which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2024
Plan of Correction
1
2
3
4
Licensee stated to transfer S3 criminal background clearance to the facility and submit proof to LPA Brown on POC due 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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2024


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 12/03/2024 06:58 PM - It Cannot Be Edited


Created By: Melody Brown On 12/03/2024 at 05:56 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: MCCOY ADULT GROUP HOME
FACILITY NUMBER: 331800085

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80068(a)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Client #2 (C2) has a complete admission agreement maintained in C2 file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2024
Plan of Correction
1
2
3
4
LIcensee stated to complete C2 Admission Agreement and submit a copy to LPA Brown on Plan of Correction (POC) due date.
Type B
Section Cited
HSC
1565(a)(2)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that the facility has the required emergency food and water as evidenced of expired emergency food at the facility with expiration date of 01/2017 and no emergecy water observed at the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2024
Plan of Correction
1
2
3
4
Licensee stated to obtrain emergency food and water and submit proof to LPA Brown on Plan of Correction (POC) due 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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2024


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 12/03/2024 06:58 PM - It Cannot Be Edited


Created By: Melody Brown On 12/03/2024 at 05:56 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: MCCOY ADULT GROUP HOME
FACILITY NUMBER: 331800085

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type B
Section Cited
CCR
85165(b)
Emergency Intervention Staff Training
(b) Staff who use, participate in, approve or provide visual checks of manual restraint or seclusion, shall have a minimum of sixteen hours of emergency intervention training and be certified for having successfully completed the training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Staff #3 (S3) completed the required Emergency Intervention Staff Training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2024
Plan of Correction
1
2
3
4
Licensee stated to submit a copy of S3 Emergency Intervention Staff Training to LPA Brown on PLan of Correction (POC) due 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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2024


LIC809 (FAS) - (06/04)
Page: 7 of 7