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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800132
Report Date: 08/10/2024
Date Signed: 08/10/2024 11:25:43 AM

Document Has Been Signed on 08/10/2024 11:25 AM - 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:CORONA HAPPY FACES ADULT HOMEFACILITY NUMBER:
331800132
ADMINISTRATOR/
DIRECTOR:		SILVA, RINAFACILITY TYPE:
735
ADDRESS:2517 STEVEN DRTELEPHONE:
(951) 734-8755
CITY:CORONASTATE: CAZIP CODE:
92879
CAPACITY: 4CENSUS: 4DATE:
08/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:28 AM
MET WITH:Licensee/Administrator Rina SilvaTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
NARRATIVE
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On 08/10/2024 at 08:28 AM, Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility to conduct the required comprehensive annual inspection. LPA Brown was greeted by an adult family member and gained access at the home. Licensee/Administrator Rina Silva was informed of the visit. LPA Brown explained the purpose of the visit to Licensee/Administrator Silva.

The facility has five (5) bedrooms, three (3) bathrooms, kitchen, dining room, living room, attached garage, backyard and a swimming pool with the required fence and locked. The facility is vendorized by Inland Regional Center (IRC). LPA Brown completed a walkthrough of the facility, review of records, client's Personal and Incidental (P&I) and medications audit.



Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD), LPA Brown observed four (4) clients during the visit. There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 78 degrees Fahrenheit. LPA Brown inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting. LPA Brown inspected client bathrooms; bathrooms were clean, and appliances were found functional. Water temperatures tested at 111 degrees Fahrenheit. The facility is equipped with combined operational smoke detectors and carbon monoxide detectors, a back-up carbon monoxide detector, charged fire extinguisher, and first aid kit with first aid book.

Posters such as; the personal rights, CCLD complaint poster, and emergency disaster plan were posted in a common area. Client medications were kept in medication room inaccessible to clients. LPA Brown did not observe night lights at the hallway leading to clients' shared bathrooms. Deficiency will be issued. The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility.
*** Continuation in LIC809C ***
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 08/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/10/2024
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: CORONA HAPPY FACES ADULT HOME
FACILITY NUMBER: 331800132
VISIT DATE: 08/10/2024
NARRATIVE
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LPA Brown observed one (1) scissor, two (2) sharp clippers, lighter, and two (2) sharp peelers not locked and accessible to clients in care. Deficiency will be issued.

Yards/Outside: One shaded patio, one (1) side gate with self-latching handle on the right side of the house that leads into the backyard, attached two (2) car garage observed. All outdoor pathways were free of obstructions. Swimming pool with required fence and lock were observed.

Food Service: LPA Brown observed two (2) days supply of perishable food and seven (7) days supply of non-perishables food and snacks. Dishes, cups, and utensils were stored properly.


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

Record Review: LPA Brown reviewed three (3) client files for admission agreements, medical assessments/physician reports, Individual Program Plan (IPP). LPA Brown observed files reviewed were complete. LPA Brown also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test result. Files reviewed were complete.

However, during the facility visit today, 08/10/2024, LPA Brown observed that the adult family member that spent the night at the home has a criminal background clearance but not associated to the facility as the family member's criminal background clearance was not transferred to the facility per Guardian database. LPA Brown informed Licensee/Administrator Silva that deficiency will be issued and Civil Penalty will be assessed during facility visit today with the amount of $100.00 for the adult family member and will continue to be assessed of $100.00 per day per citation until corrected for not transferring the adult family member's criminal record clearance to the facility.

LPA Brown audited three (3) clients’ medications and no issues were observed. LPA Brown audited three (3) client's Personal and Incidental (P&I) and no issues observed.

Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809D, LIC421BG and Appeal Rights were discussed, and copies were provided to Licensee/Administrator Rina Silva.

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

DATE: 08/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/10/2024 11:25 AM - It Cannot Be Edited


Created By: Melody Brown On 08/10/2024 at 10:53 AM
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: CORONA HAPPY FACES ADULT HOME
FACILITY NUMBER: 331800132

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 the one (1) scissor, two (2) sharp clippers, lighter, and two (2) sharp peelers wer locked and not accessible to clients in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/11/2024
Plan of Correction
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Licensee stated to train all staff on CCR 80087(g) and submit proof to LPA Brown on 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: 08/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 08/10/2024 11:25 AM - It Cannot Be Edited


Created By: Melody Brown On 08/10/2024 at 10:53 AM
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: CORONA HAPPY FACES ADULT HOME
FACILITY NUMBER: 331800132

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2024

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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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that night lights are maintained in hallways and passages to nonprivate bathrooms which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
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Licensee stated to obtain/purchase night lights and submit proof to LPA Brown on Plan of Correction (POC) due date.
Type B
Section Cited
CCR
80019(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 80019(f) or

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 the adult family member's criminal record clearance was transferred to the facility before allowing the adult family member to stay overnight at the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
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Licensee stated to transfer the criminal record clearance of the adult family member to the facility and submit proof to LPA Brown on 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: 08/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2024


LIC809 (FAS) - (06/04)
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