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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800106
Report Date: 06/20/2024
Date Signed: 06/20/2024 05:31:21 PM

Document Has Been Signed on 06/20/2024 05:31 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
RIVERSIDE, CA 92507
FACILITY NAME:INSPIRING LIVES ARFFACILITY NUMBER:
331800106
ADMINISTRATOR/
DIRECTOR:		SHALANA CARTERFACILITY TYPE:
735
ADDRESS:19205 STROUT LANETELEPHONE:
(951) 776-8183
CITY:RIVERSIDESTATE: CAZIP CODE:
92508
CAPACITY: 6CENSUS: 3DATE:
06/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:S'halana Carter, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction and visit purpose. Upon arrival LPA learned that three (3) clients reside at this facility and there are currently two (2) caregivers present. There is an Infection Control Plan on file.

Client Records-Incident Reports/Clients Rights-Information/Dental- LPA began review of client records. Three (3) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment-one missing, and TB test results-one missing, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification.

Personnel Records/Training/and Staffing- LPA began review of employee records- One (1) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrator certification; expiration date 2/28/2026.



Food Service- Food prep areas are clean and organized. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a locked location for chemicals and sharps in the hallway.

(Continued on LIC809C)
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2024
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 6
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: INSPIRING LIVES ARF
FACILITY NUMBER: 331800106
VISIT DATE: 06/20/2024
NARRATIVE
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(Continuation from Page 2)

Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. LPA observed the facility to be clean and needs repair. The home is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured 111.0 degrees F. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. The LIC 610, emergency disaster plan is maintained. There are no firearms at this home and no bodies of water observed.

Medications- are centrally stored. There is a locked cabinet allocated for medication storage. Centrally stored medication and destruction logs are maintained. Medications reviewed appear to have been dispensed accurately.

P&I- was reviewed. LPA observed that the facility maintains a separate log for each individuals’ monies. Money counted count was accurately reflected on the ledger.

LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguisher was recharged this year, 05/9/2024. The facility is conducting emergency disaster/fire drills monthly; last done on 05/1/2024.

Based on the information received during this visit today in the areas reviewed, eight (8) deficiencies are being cited per Title 22, Division 6 of The California Code of Regulations.

This LIC 809, 809D and Appeal Rights report was reviewed with the facility representative and a copy was provided.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
LIC809 (FAS) - (06/04)
Page: 6 of 6
Document Has Been Signed on 06/20/2024 05:31 PM - It Cannot Be Edited


Created By: Yolanda Delgado On 06/20/2024 at 05:01 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: INSPIRING LIVES ARF
FACILITY NUMBER: 331800106

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA Delgado's observation and interview, the licensee did not comply with the section cited above in stove top pilots did not all come on, Eastside gate needs repair which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/04/2024
Plan of Correction
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2
3
4
Licensee will correct stovetop range and Eastside gate and will email photographs to LPA by POC due date.
Type B
Section Cited
CCR
80087(a)(1)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (1) The licensee shall take measures to keep the facility free of flies and other insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA Delgado's observation and interview, the licensee did not comply with the section cited above in ants were observed in the common bathroom on the 2nd floor which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/04/2024
Plan of Correction
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3
4
Licensee will take measures to keep the facility free of insects and email plan to 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:Jazmond D Harris
LICENSING EVALUATOR NAME:Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 06/20/2024 05:31 PM - It Cannot Be Edited


Created By: Yolanda Delgado On 06/20/2024 at 05:01 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: INSPIRING LIVES ARF
FACILITY NUMBER: 331800106

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA Delgado's observation and interview, the licensee did not comply with the section cited above in 2nd floor window screen missing which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/04/2024
Plan of Correction
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3
4
Licensee will obtain a window screen and email a picture or invoice to LPA by POC due date.
Type B
Section Cited
CCR
85088(c)(2)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (2) Bedroom furniture including, in addition to (c)(1) above, for each client, a chair, a night stand, and a lamp or lights necessary for reading.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on LPA Delgado's observation and interview, the licensee did not comply with the section cited above in bedrooms #2 and #4 are not setup for a client room which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/04/2024
Plan of Correction
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Licensee will obtain furniture for the designated rooms or submit an LIC200 to change capacity (email copy) to 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:Jazmond D Harris
LICENSING EVALUATOR NAME:Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 06/20/2024 05:31 PM - It Cannot Be Edited


Created By: Yolanda Delgado On 06/20/2024 at 05:01 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: INSPIRING LIVES ARF
FACILITY NUMBER: 331800106

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(e)(2)
Fixtures, Furniture, Equipment, and Supplies
(e) Emergency lighting, which shall include at a minimum working flashlights or other battery-powered lighting, shall be maintained and readily available in areas accessible to clients and staff. (2) Night lights shall be maintained in hallways and passages to nonprivate bathrooms.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA Delgado's observation and interview, the licensee did not comply with the section cited above in no night light observed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/04/2024
Plan of Correction
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Licensee will obtain night light for common bathrooms and email a photograph to LPA by POC due date.
Type B
Section Cited
CCR
85087.2(b)
Outdoor Activity Space
(b) The outdoor activity area shall provide a shaded area, and shall be comfortable, and furnished for outdoor use.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA Delgado's observation and interview, the licensee did not comply with the section cited above in no patio table observed with sufficient chairs which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/04/2024
Plan of Correction
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Licensee will obtain patio furniture and additinal chairs and email a photograph to 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:Jazmond D Harris
LICENSING EVALUATOR NAME:Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 06/20/2024 05:31 PM - It Cannot Be Edited


Created By: Yolanda Delgado On 06/20/2024 at 05:01 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: INSPIRING LIVES ARF
FACILITY NUMBER: 331800106

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.2(b)(1)(C)
Needs and Services Plan
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (C) The written medical assessment specified in Section 80069.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in C1 current written assessment was not observed in file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/04/2024
Plan of Correction
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Licensee will obtain a written medical assessment for C1 and email a copy to LPA by POC due date.
Type B
Section Cited
CCR
80069(c)(1)
Client Medical Assessments
(c) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in C1 results of an examination for communicable TB was not observed in file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/04/2024
Plan of Correction
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Licensee will obtain a results for C1 TB and email a copy to 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:Jazmond D Harris
LICENSING EVALUATOR NAME:Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024


LIC809 (FAS) - (06/04)
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