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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800154
Report Date: 04/18/2024
Date Signed: 04/18/2024 12:41:54 PM

Document Has Been Signed on 04/18/2024 12:41 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:CASA ALISAFACILITY NUMBER:
331800154
ADMINISTRATOR/
DIRECTOR:		ALCOCER, PETER KFACILITY TYPE:
735
ADDRESS:15849 ALISA VIEJO COURTTELEPHONE:
(714) 448-0533
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY: 4CENSUS: 4DATE:
04/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Peter Alcocer, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA), Stephanie Martinez, made an unannounced visit to the facility, accompanied by Licensing Program Manager (LPM), Rikesha Stamps, and LPA, Seo Jeon, for the purpose of conducting a required annual inspection. The LPAs and LPM were greeted and allowed to enter the facility to conduct the inspection. On today’s visit the LPAs and LPM met with Administrator, Peter Alcocer; he was notified of the purpose for their visit.

PHYSICAL PLANT: The Licensee is operating the facility within the conditions and limitations specified on the license. Outdoor and indoor passageways are kept free of obstruction. No pool or body of water was observed on the property. According to the Administrator, there are no weapons kept in the home. Disinfectants, cleaning solutions, and poisons were inaccessible to clients in care. A comfortable temperature was being maintained in the home. There was sufficient lighting in all rooms to ensure the comfort and safety of clients. Hot water was tested and observed to be within regulatory requirements. Toilets, hand washing and bathing facilities were kept safe and in operating condition. Additional equipment for physically handicapped clients is available. The smoke and carbon monoxide alarms were tested and found to be operable. LPA Martinez observed an unknown amount of empty bottles on the side of the home; the grass in the back yard was observed to be over grown; a patio chair on the balcony was observed to be worn and tearing; and observed the bedroom of C1 to be dirty (empty bottles; dust on the dresser drawer; bags, boxes, and clothing on the ground); and a toilet was observed in the corner of the backyard. This poses a potential threat to the health, safety, and personal rights of the clients in care. Therefore, a citation will be issued.

FOOD SERVICE: There was a variety of food which appeared to be selected and stored in a safe and healthful manner. Food supply of nonperishable and perishable foods was sufficient. The kitchen was observed to be clean.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2024
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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CASA ALISA
FACILITY NUMBER: 331800154
VISIT DATE: 04/18/2024
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RECORD REVIEW: Staff files had required training; including, but not limited to, first aid training. Staff present had the required criminal record clearances. An Individual Program Plan (IPP) and Medical Assessment (Physician's Report) was on file for clients in care. There are no clients in care who have a restricted health condition. Administrator Alcocer has an active Administrator's certificate, which expires on 04/18/2025. A fire and earthquake drill was completed 04/01/2024.

MEDICATION: Medication were reviewed for clients in care. All medications were labeled and maintained in compliance with label instructions and State and Federal law. Medications (2) were observed to be accessible to C2 in their bathroom. C2's medical assessment shows they are not capable of storing or administering their own medication. This poses a potential threat to the health and safety of the clients in care. Therefore, a citation will be issued.

An exit interview was conducted; this report was reviewed with Administrator Alcocer and a copy was provided, along with the LIC 809D, LIC 811, and instructions on appeal rights.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/18/2024 12:41 PM - It Cannot Be Edited


Created By: Stephanie Martinez On 04/18/2024 at 11:56 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
RIVERSIDE, CA 92507

FACILITY NAME: CASA ALISA
FACILITY NUMBER: 331800154

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
Buildings 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
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Based on observation, the licensee did not comply with the section cited above. LPA observed an unknown amount of empty bottles on the side of the home; the grass in the back yard was over grown; a patio chair on the balcony was worn & tearing; C1's bedroom to be dirty; & a toilet in the corner of the backyard. This poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 04/25/2024
Plan of Correction
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The Administrator stated the above areas would be addressed and photos would be submitted as proof of their corrections.
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:Rikesha Stamps
LICENSING EVALUATOR NAME:Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/18/2024 12:41 PM - It Cannot Be Edited


Created By: Stephanie Martinez On 04/18/2024 at 12:19 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: CASA ALISA
FACILITY NUMBER: 331800154

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(1)
Health Related Services: (k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in two out of two medications observed to be accessible in the bathroom of C2. C2's medical assessment shows the client does not have the capability to store or administer their own medication. This poses an immediate health, safety and personal rights risk to persons in care.
POC Due Date: 04/18/2024
Plan of Correction
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The medications were immediately removed from the area and placed in an inaccessible area.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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4
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:Rikesha Stamps
LICENSING EVALUATOR NAME:Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2024


LIC809 (FAS) - (06/04)
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