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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800183
Report Date: 06/17/2023
Date Signed: 06/17/2023 11:49:25 AM

Document Has Been Signed on 06/17/2023 11:49 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:TELECARE RIVERSIDE COUNTY CRISIS RESIDENTIAL-LAGOSFACILITY NUMBER:
331800183
ADMINISTRATOR:SHIVANI ESCAMILLAFACILITY TYPE:
772
ADDRESS:9890 COUNTY FARM ROAD B-CTELEPHONE:
(951) 509-8320
CITY:RIVERSIDESTATE: CAZIP CODE:
92503
CAPACITY: 16CENSUS: 16DATE:
06/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Maricella BecerraTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit on 06/17/2023 at 08:45 a.m. LPA was granted entry and met with staff member, Maricela Becerra, who was informed of the purpose of the visit. At the time of the visit there was (6) staff and (16) clients present.

The facility is a one-story building with (16) bedrooms and (6) bathrooms. The clients served are adults between the ages of 18-59. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted a staff and client interviews. LPA observed the following:

Infection Control: The LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements. LPA reviewed staff records and found that all staff had infection control training.



Physical Plant: LPA observed the client bedrooms and staff office. Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor courtyard area was observed to be free of hazards. There are no pools or bodies of water. LPA observed outdoor furniture and shaded area for clients. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to clients. The smoke detector and carbon monoxide was operational, and the hot water temperature 111 F. LPA was informed the county conducts routine inspections on the smoke alarms.

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. A full menu with alternative food options was posted on the front of the refrigerator door.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2023
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: TELECARE RIVERSIDE COUNTY CRISIS RESIDENTIAL-LAGOS
FACILITY NUMBER: 331800183
VISIT DATE: 06/17/2023
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Care & Supervision/Administration: Adequate staff are present for the supervision of clients during the visit. LPA also reviewed the staff scheduled showing adequate staff coverage. 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.

Record Review and Resident/Staff Files: LPA reviewed five (5) staff files and training. All staff have criminal clearance and updated training along with CPR/First Aid Certification. Five (5) client files were reviewed, and possessed all required paperwork.



Health Related Services/ Incidental Medical Services: All client medication was locked in the Nurse/Medication room. LPA reviewed client medications for five (5) 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. The plan the facility currently has on file does not meet the department requirements. LPA will provide the facility with a copy of the updated Emergency and Disaster Plan. A technical violation will be issued. LPA reviewed documentation showing the facility's last fire and earthquake drills, which met the department requirements. LPA observed all facility exits were clear from obstructions. LPA reviewed documentation showing the facility's last fire and earthquake drills, which met the department requirements. LPA observed all facility exits were clear from obstructions.

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, Jonathan Lewis.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2023
LIC809 (FAS) - (06/04)
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