331800086-1-29-2024-18-AS-JARA-CZXVZR-20240129155312

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331800086
Report Date: 01/29/2024
Date Signed: 01/29/2024 03:53:31 PM

Document Has Been Signed on 01/29/2024 03:53 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	CALIFORNIA HOME FOR THE ADULT DEAF (CHAD)		FACILITY NUMBER:	331800086
ADMINISTRATOR:	DANNY BARRETT		FACILITY TYPE:	740
ADDRESS:	3615 CROWELL AVE		TELEPHONE:	(626) 701-8960
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92504
CAPACITY:	6	CENSUS: 5	DATE:	01/29/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:09 PM
MET WITH:	Staff, Joseph Valdez		TIME COMPLETED:	04:00 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	Licensing Program Analyst (LPA) Janira Arreola and conducted a required annual visit. LPA was greeted and was granted entry and met with Staff, Joseph Valdez and spoke with Administrator Daniel Barrett over the phone who was informed of the purpose of the visit. LPA was accompanied by a Community Care Licensing approved American Sign Language interpreter to assist LPA's communications with facility staff and residents. At the time of visit there were (4) clients and (2) staff present. The facility is a one story home with (6) bedrooms and (4) bathrooms. The facility does not have a pool or fire arms. The facility is a residential care facility for the elderly serving elderly ages 60 and above. LPA observed the following: Infection Control: LPA observed hand hygiene supplies, PPE equipment and cleaning supplies to do regular cleaning of the facility. The facility has a infection control plan on file. Physical Plant: Physical plant, floors, windows, and doors were observed to be clean and fixtures and furniture were present and in good repair. The facility's outdoor area was observed to be free of hazards. Laundry equipment was observed to be in good working condition. The carbon monoxide detector was tested and operational during the visit. LPA observed beeping noise and error code coming from the fire panel in the home. The administrator informed the LPA that this was recently installed in the facility. Technical note was issued for facility staff to have this inspected. Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required food items.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CALIFORNIA HOME FOR THE ADULT DEAF (CHAD)	FACILITY NUMBER: 331800086
	VISIT DATE: 01/29/2024

NARRATIVE

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Record Review and Resident/Staff Files: LPA reviewed staff files and training. LPA found that (2) staff did not have a documented physical exam on file. deficiency was cited and plan of correction was documented with administrator. (1) staff was found to not have current annual 20 hour training, LPA documented technical note and documented date when the staff would conduct the training. Client files were reviewed and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: All client medication was locked in a kitchen cabinet. LPA reviewed client medications and found that MARS and medication was accounted for and had required labeling.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. Technical note was documented for staff to update to new LIC610D. Administrator was unable to provide documentation on most recent drill. deficiency was cited and plan of correction was created with administrator. The documentation did not meet the department standards and technical note was documented.

An exit interview was conducted with staff, Joseph Valdez where this report and deficiency pages and appeal rights were reviewed and provided to them.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/29/2024 03:53 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CALIFORNIA HOME FOR THE ADULT DEAF (CHAD)	FACILITY NUMBER: 331800086
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, the licensee did not comply with the section cited above with drill that was not documented or conducted within the required timeframe which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/29/2024
	Plan of Correction
1 2 3 4	The administrator agreed to conduct and document the drill and send to LPA by the POC due date.

Type B

Section Cited

CCR

87411(f)

(f) All personnel...shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, the licensee did not comply with the section cited above with (2) staff that did not have a documented or conducted health physcal before working at the facility which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/29/2024
	Plan of Correction
1 2 3 4	The administrator agreed to have staff conduct the health screening and send proof to the LPA by 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: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024

LIC809 (FAS) - (06/04)

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