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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800088
Report Date: 02/16/2024
Date Signed: 02/16/2024 02:43:32 PM

Document Has Been Signed on 02/16/2024 02:43 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:STEWART'S RESIDENTIAL CAREFACILITY NUMBER:
331800088
ADMINISTRATOR:STEWART, REUBENFACILITY TYPE:
735
ADDRESS:3631 MARI DRIVETELEPHONE:
(951) 399-0623
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92530
CAPACITY: 4CENSUS: 4DATE:
02/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Maureen Sevilla- Facility ManagerTIME COMPLETED:
02:55 PM
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Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Facility Manager Maureen Sevilla and was granted entry to the facility.

The facility is an Adult Residential Facility (ARF) licensed for a capacity of four (4) ambulatory clients. The facility is level 4i vendorized by Inland Regional Center (IRC). The current census is four (4) clients. LPA was accompanied by Facility Manager to conduct a general overall inspection, which included, but was not limited to, the following:

The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to interior and exterior passageways. The facility is maintained at a comfortable temperature. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperature in the bathrooms to be at 109.7 degrees F. The facility is equipped with operating smoke detectors. LPA discovered that the facility does not have a carbon monoxide alarm in the facility. The facility will be issued a deficiency for not having a carbon monoxide alarm. Postings such as the facility license, personal rights, the CCL complaint poster, labor laws, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. There was a designated storage space for client files and staff files. The medications are kept inside a cabinet in the hallway inaccessible to the clients. Non-perishable and perishable food supply is sufficient for the clients in care. The facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

LPA reviewed four (4) client files for admission agreements, updated physician reports, and needs and services plans.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/16/2024
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 4
Document Has Been Signed on 02/16/2024 02:43 PM - It Cannot Be Edited


Created By: Ryan Gardner On 02/16/2024 at 02:05 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
RIVERSIDE, CA 92507

FACILITY NAME: STEWART'S RESIDENTIAL CARE
FACILITY NUMBER: 331800088

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1503.2
General Provisions
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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This requirement is not met as evidenced based on observation and interview, the licensee did not comply with the section cited above evidenced by not having a carbon monoxide detector in the facility which poses an immediate health, safety, or personal rights risk to persons in care.
POC Due Date: 02/17/2024
Plan of Correction
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The licensee has agreed to read health and safety code (HSC) 1503.2 entirely and send LPA a statement of understanding that the HSC was read and understood. The licensee has agreed to purchase and install a carbon monoxide detector by the POC due date. POC is due by 2/17/2024.
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:Ryan Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 02/16/2024 02:43 PM - It Cannot Be Edited


Created By: Ryan Gardner On 02/16/2024 at 02:05 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
RIVERSIDE, CA 92507

FACILITY NAME: STEWART'S RESIDENTIAL CARE
FACILITY NUMBER: 331800088

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(b)
Client Medical Assessments
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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This requirement is not met as evidenced based on document review and interview, the licensee did not comply with the section cited above evidenced by admitting Client C1 to the facility without a medical assessment which poses a potential health, safety, or personal rights risk to persons in care.
POC Due Date: 02/28/2024
Plan of Correction
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The licensee has agreed to read regulation 80069 entirely and send LPA a statement of understanding that the regulation was read and understood. The licensee has agreed to have a medical assessment completed for Client C1 by the POC due date. POC is due by 2/28/2024.
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:Ryan Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2024


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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: STEWART'S RESIDENTIAL CARE
FACILITY NUMBER: 331800088
VISIT DATE: 02/16/2024
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LPA discovered that Client C1 was admitted to the facility on 7/19/2023 and as of today, 2/16/2024, C1 does not have a medical assessment. The facility will be issued a deficiency for admitting C1 to the facility without a medical assessment. LPA reviewed three (3) staff files for First Aid/CPR certifications, criminal record clearances, trainings, and health screenings.

Based on the observations made during today’s visit, two (2) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809), LIC811, and LIC809D forms were discussed and provided to Facility Manager Maureen Sevilla, along with a copy of the appeal rights.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024
LIC809 (FAS) - (06/04)
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