331800126-9-29-2023-18-AS-SMAZ-CW5RME-20230929130838

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331800126
Report Date: 09/29/2023
Date Signed: 09/29/2023 01:09:44 PM

Document Has Been Signed on 09/29/2023 01:09 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	NUEVO RANCH RESIDENTIAL FACILITY		FACILITY NUMBER:	331800126
ADMINISTRATOR:	WALKER, ADRIENNE		FACILITY TYPE:	735
ADDRESS:	27031 NUEVO ROAD		TELEPHONE:	(951) 796-7623
CITY:	PERRIS	STATE: CA	ZIP CODE:	92571
CAPACITY: 5		CENSUS: 2	DATE:	09/29/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:24 AM
MET WITH:	Adrienne Walker - Administrator		TIME COMPLETED:	01:21 PM

NARRATIVE

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Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit. LPA was granted entry and met with Yanet Esparaza, who was informed of the purpose of the visit. Administrator Adrienne Walker arrived shortly after to assist LPA. At the time of the visit there was (1) staff and (0) client present.

The facility is a one story home with (5) bedrooms and (3) bathrooms with an attached garage, and a backyard. The clients served are adults between the ages of 18-59. The facility does not contain any bodies of water, firearms, or ammunition on the property. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following:

Physical Plant: LPA observed the client bedrooms, bathrooms, and staff office. Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair and were present. The outdoor area was observed to be free of hazards and contained outdoor furniture and shaded area for clients. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were locked and inaccessible to clients. The smoke detector and carbon monoxide was operational, and the hot water temperature 120F.

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 2-day supply of perishable and 7-day supply of non-perishable foods.

Care & Supervision/Administration: Adequate staff are present for the supervision of clients during the visit. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The listed administrator possesses a current administrator's certificate.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: NUEVO RANCH RESIDENTIAL FACILITY	FACILITY NUMBER: 331800126
	VISIT DATE: 09/29/2023

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Record Review and Resident/Staff Files: LPA was not able to review staff files due to Licensee not having the files available for review during the time of the inspection. This does not meet department requirements and a deficiency along with a plan of correction will be issued. LPA was not able to review the facility's Infection Control Plan due to the licensee not having the file available for review during the time of the inspection. A deficiency will be issued along with a plan of correction. Two (2) client files were reviewed, and possessed all required paperwork. LPA reviewed one (1) clients P&I and found no discrepancies.

Health Related Services/ Incidental Medical Services: All client medication was locked in hallway closet. LPA reviewed medications for two (2) clients and found all medication listed on MARS and all required labeling was found to be in place.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing the facility's last fire and earthquake drill was conducted on 09/21/2023, which met the department requirements. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies in the garage and first aid kit with all required items.

No deficiencies were cited at the time of the visit.

An exit interview was conducted where a copy of this report was provided to Administrator, Adrienne Walker.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/29/2023 01:09 PM - It Cannot Be Edited

Created By: Sara Martinez On 09/29/2023 at 12:50 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: NUEVO RANCH RESIDENTIAL FACILITY	FACILITY NUMBER: 331800126
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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 in having the Infection Control Plan available at the facility during LPA's inspection which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/06/2023
	Plan of Correction
1 2 3 4	Licensee will submit proof of Infection Control Plan to LPA by the agree plan of correction date 10/06/2023. Licensee will agree to have Infection Control Plan available at the facility.

Type B

Section Cited

CCR

80066(a)

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 in having the staff files/ personnel records available at the facility during LPA's inspection and record review which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/06/2023
	Plan of Correction
1 2 3 4	Licensee will submit proof of facility staff files and all of the Department's required documents to LPA by the agreed plan of correction date. Licensee will agree to have staff files available at the facility.

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:

Joel Esquivel

LICENSING EVALUATOR NAME:

Sara Martinez

LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

LIC809 (FAS) - (06/04)

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