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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800192
Report Date: 01/09/2025
Date Signed: 01/09/2025 05:05:37 PM

Document Has Been Signed on 01/09/2025 05:05 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
, CA 92507
FACILITY NAME:MEMBERS MVPFACILITY NUMBER:
331800192
ADMINISTRATOR/
DIRECTOR:		NIKKI VON JENAFACILITY TYPE:
735
ADDRESS:31588 VINTNERS POINTE CTTELEPHONE:
(951) 325-5506
CITY:WINCHESTERSTATE: CAZIP CODE:
92596
CAPACITY: 4CENSUS: 4DATE:
01/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:55 PM
MET WITH:Administrator Nikki Von JennaTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
NARRATIVE
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On 01/09/2025 at 02:55 PM, 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 a staff and gained access at the home. Administrator NIkki Von Jenna was contacted and informed of the visit. LPA Brown explained the purpose of the visit to Staff #2 (S2). Administrator NIkki Von Jenna arrived during the visit. LPA Brown explained the purpose of the visit to Administrator Von Jenna.

The facility has four (4) bedrooms for the clients, two (2) bedrooms for the staff and four (4) client/staff shared bathrooms, kitchen, dining room, living room, laundry room, attached garage, and backyard. The facility is vendorized by Inland Regional Center (IRC). LPA Brown completed a walkthrough of the facility, review of records, medications audit and personal and incidental (P&I) 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 71 degrees Fahrenheit. LPA Brown inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs, and sufficient lighting. LPA Brown inspected client bathrooms; bathrooms were clean, and appliances were found functional. Water temperatures tested at 122.1 degrees Fahrenheit. Deficiency will be issued. The facility is equipped with operational smoke detectors, carbon monoxide detector, charged two (2) fire extinguishers, and first aid kit with first aid book.

Posters such as; the Personal Rights, CCLD complaint poster, labor laws, Theft & Loss Policy, Grievance Policy and emergency disaster plan were posted in a common area. Client medications were kept in secure cabinets inaccessible to clients. LPA Brown observed night lights at the hallway leading to clients' shared bathrooms. 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: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2025
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: MEMBERS MVP
FACILITY NUMBER: 331800192
VISIT DATE: 01/09/2025
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Yards/Outside: One shaded patio, one (1) side gate with self-latching handle on the left side of the house that leads into the backyard, attached four (4) car garage observed. All outdoor pathways were free of obstructions.

Food Service: LPA observed two (2) day(s) supply of perishable food and seven (7) day(s) 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 noted that the facility has Infection Control Pla, Liability Insurance, and Surety Bond maintained at the facility. LPA Brown reviewed four (4) client files for admission agreements, medical assessments/physician reports, Centrally Stored Medication List and Individual Program Plan (IPP). LPA Brown observed files reviewed were complete. LPA Brown also reviewed staff and administrator's file for First Aid/CPR and Emergency Intervention/CPI certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test result. LPA Brown observed no issues, files reviewed were complete.

LPA Brown audited two (2) clients’ medications and no issues were observed. LPA Brown audited two (2) client's P&I and no issue observed.

One (1) deficiency was cited during this visit. An exit interview was conducted where this report LIC809, LIC809D, and Appeal Rights were discussed, and copies were provided to Administrator Nikki Von Jenna.

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

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/09/2025 05:05 PM - It Cannot Be Edited


Created By: Melody Brown On 01/09/2025 at 04:27 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
, CA 92507

FACILITY NAME: MEMBERS MVP
FACILITY NUMBER: 331800192

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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 by not ensuring that the hot water in the clients' shared bathrooms were maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/16/2025
Plan of Correction
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Licensee stated to regulate the hot water in clients shared bathrooms to not less 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C) and submit proof to LPA Brown by the 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: 01/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2025


LIC809 (FAS) - (06/04)
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