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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800088
Report Date: 01/23/2025
Date Signed: 01/23/2025 01:31:55 PM

Document Has Been Signed on 01/23/2025 01:31 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:STEWART'S RESIDENTIAL CAREFACILITY NUMBER:
331800088
ADMINISTRATOR/
DIRECTOR:		STEWART, REUBENFACILITY TYPE:
735
ADDRESS:3631 MARI DRIVETELEPHONE:
(951) 399-0623
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92530
CAPACITY: 4CENSUS: 3DATE:
01/23/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:16 AM
MET WITH:Residential Director Agbelusi AdegboyegaTIME VISIT/
INSPECTION COMPLETED:
01:40 PM
NARRATIVE
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On 01/23/2025 at 09:16 AM, Licensing Program Analyst (LPA) Melody Brown arrived an unannounced visit to the facility to conduct the required comprehensive annual inspection. LPA Brown was greeted by Residential Director Agbelusi Adegboyega and gained access at the home. LPA Brown explained the purpose of the visit to Residential Director Adegboyega.

The facility has four (4) bedrooms, two (2) and 1/2 bathrooms, kitchen, dining room, living room, attached garage, and backyard. The facility is level 4i vendorized by Inland Regional Center (IRC). LPA Brown completed a walkthrough of the facility, review of records, medications audit and Personal & Incidental (P&I) audit.



Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). LPA Brown observed no client during the visit. The three (3) clients were out in the community. There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 70 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 105 degrees Fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide detectors, charged fire extinguisher, and with first aid book. However, LPA Brown observed incomplete first aid kit maintained at the facility. Deficiency will be issued.

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, emergency food and water. There are no firearms and ammunition in the facility. *** Cont. in LIC809C ***
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2025
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: STEWART'S RESIDENTIAL CARE
FACILITY NUMBER: 331800088
VISIT DATE: 01/23/2025
NARRATIVE
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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: LPA 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. However, LPA Brown observed one (1) box of food stored with cleaning supplies. Deficiency will be issued. During the visit, Residential Director Adegboyega removed the food stored in the cleaning supplies closet.


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

Record Review: LPA Brown observed that the facility has Infection Control Plan, updated Surety Bond and updated Liability Insurance maintained at the facility. LPA Brown reviewed three (3) client files for admission agreements, medical assessments/physician reports, Individual Program Plan (IPP) and Centrally Stored Medication List. LPA Brown observed files reviewed were complete. LPA Brown also reviewed staff and administrator's file for First Aid/CPR certification and Emergency Intervention/CPI certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test result. LPA Brown observed Staff #2 (S2) and Staff #3 (S3) have expired First Aid/CPR training. Deficiency will be issued.

LPA Brown audited two (2) clients’ medications and LPA Brown observed that staffs at the facility are not assisting Client #1 (C1), Client #2 (C2) and Client #3 (C3) with the self-administration of prescription and nonprescription medications as evidenced of C1 one (1) medication was not given per C1's doctor's order and two (2) missing medications, C2 has three (3) missing medications and C3 has two (2) missing medications at the facility. Deficiency will be issued. LPA Brown audited three (3) client's P&I and no issues observed.

Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, and Appeal Rights were discussed, and copies were provided to Residential Director Agbelusi Adegboyega.

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

DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 01/23/2025 01:31 PM - It Cannot Be Edited


Created By: Melody Brown On 01/23/2025 at 12:11 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: STEWART'S RESIDENTIAL CARE
FACILITY NUMBER: 331800088

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

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 #2 (S2) and Staff #3 (S3) have updated First Aid certification/training which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/24/2025
Plan of Correction
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LIcensee stated to submit proof of enrollment or completed certification in First Aid for S2 and S3 to LPA Brown by the Plan of Correction (POC) due date.
Type A
Section Cited
CCR
80076(a)(16)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (16) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies.

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 cleaning supplies were stored separate from food supplies which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/24/2025
Plan of Correction
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Licensee immediately removed the food observed in the locked cleaning supplies closet during the visit.
Licensee stated to train all staff on CCR 80076(a)(16) and submit proof of staff training log to LPA Brown by the 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: 01/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 01/23/2025 01:31 PM - It Cannot Be Edited


Created By: Melody Brown On 01/23/2025 at 12:11 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: STEWART'S RESIDENTIAL CARE
FACILITY NUMBER: 331800088

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

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 staffs at the facility are assisting Client #1 (C1), Client #2 (C2) and Client #3 (C3) with the self-administration of prescription and nonprescription medications as evidenced of C1 one (1) medication was not given per C1's doctor's order and two (2) missing medications, C2 has three (3) missing medications and C3 has two (2) missing medications which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/24/2025
Plan of Correction
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Licensee stated to train all staff on CCR 80075(b) and submit proof of staff training log to LPA Brown by the Plan of Corretion (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: 01/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 01/23/2025 01:31 PM - It Cannot Be Edited


Created By: Melody Brown On 01/23/2025 at 12:11 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: STEWART'S RESIDENTIAL CARE
FACILITY NUMBER: 331800088

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(g)
Health-Related Services
(g) If the facility has no medical unit on the grounds, first aid supplies shall be maintained and be readily available in a central location in the facility.

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 a complete First Aid kit was maintained at the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2025
Plan of Correction
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Licensee stated to obtain/purchase complete First Aid Kit and submit proof to LPA Brown by the 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: 01/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2025


LIC809 (FAS) - (06/04)
Page: 5 of 5