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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800219
Report Date: 10/22/2024
Date Signed: 10/22/2024 01:39:09 PM

Document Has Been Signed on 10/22/2024 01:39 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:AUSTIN SMALL ARIZONA FAMILY HOMEFACILITY NUMBER:
331800219
ADMINISTRATOR/
DIRECTOR:		AUSTIN, ADELINEFACILITY TYPE:
735
ADDRESS:867 MONTAGUE DRTELEPHONE:
(951) 272-9651
CITY:CORONASTATE: CAZIP CODE:
92879
CAPACITY: 6CENSUS: 4DATE:
10/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Administrator Alexandria AustinTIME VISIT/
INSPECTION COMPLETED:
01:39 PM
NARRATIVE
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On 10/22/2024 at 09:05 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 a staff and gained access at the home. Administrator Alexandria Austin was contacted and informed of the visit. LPA Brown explained the purpose of the visit to Administrator Austin.

The facility has six (6) bedrooms, three (3) and a half bathrooms, kitchen, dining room, living room, family room, attached garage, and backyard. Per documents review, the facility submitted a letter informing Community Care Licensing Division (CCLD) of the alteration made to the facility. The facility is vendorized by Inland Regional Center (IRC). LPA Brown completed a walkthrough of the facility, review of records, and medications audit and Personal and Incidental (P&I) audit.



Physical Plant: The facility is operating in the capacity approved by CCLD, LPA Brown observed two (2) clients during the visit. Two (2) clients were out in the community. There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 74 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 temperature tested at 76.4 degrees Fahrenheit. Deficiency will be issued. The facility is equipped with operational smoke detectors, carbon monoxide detectors, charged fire extinguisher, and first aid kit with first aid book.

Emergency disaster plan was posted in a common area, but LPA Brown did not observe the CCLD Complaint Poster posted and the Personal Rights. Deficiency will be issued. Client medications were kept in secure cabinets inaccessible to clients. LPA Brown observed no night lights at the hallway leading to clients' shared bathrooms. Deficiency will be issued. *** Continuation in LIC809C ***
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2024
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: AUSTIN SMALL ARIZONA FAMILY HOME
FACILITY NUMBER: 331800219
VISIT DATE: 10/22/2024
NARRATIVE
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The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility.

However, during the tour of the facility, LPA Brown observed three (3) scissors in the garage not locked and accessible to clients in care. Also, one (1) scissor and one (1) wine bottle opener with sharp edge was observed in the family room, not locked and accessible to clients in care. Furthermore, a sharp gardening tool was also observed in the backyard, 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 one (1) car garage observed. All outdoor pathways were free of obstructions.

Food Service: LPAs 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 observed no Infection Control Plan maintained at the facility. Deficiency will be issued. LPA Brown reviewed three (3) client files for admission agreements, medical assessments/physician reports, Centrally Stored Medication Lists, 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 three (3) clients’ medications and observed that staffs at the facility are not assisting their clients with self-administration of their medications as evidenced of two (2) medications of Client #1, one (1) medication of Client #2 (C2) and one (1) medication of client #3 (C3) were missing during medication audit. Deficiency will be issued. LPA Brown audited three (3) client's P&I and no issue was observed.

Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, and Appeal Rights were discussed, and copies were provided to Administrator Alexandria Austin.

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

DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 10/22/2024 01:39 PM - It Cannot Be Edited


Created By: Melody Brown On 10/22/2024 at 12:39 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: AUSTIN SMALL ARIZONA FAMILY HOME
FACILITY NUMBER: 331800219

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2024

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 three (3) scissors in the garage was locked and not accessible to clients in care. Also, the Licensee did not ensure that one (1) scissor and one (1) wine bottle opener with sharp edge was observed in the family room, was locked and not accessible to clients in care. Furthermore, the Licensee did not ensure that the sharp gardening tool in the backyard was 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: 10/23/2024
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.
Type A
Section Cited
CCR
80075(b)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

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 facility staffs are assisting clients with self-administration of their medications as evidenced of two (2) medications of Client #1, one (1) medication of Client #2 (C2) and one (1) medication of client #3 (C3) were missing during medication auditcwhich poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2024
Plan of Correction
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Licensee stated to train all staff on CCR 80075(b) and submit proof of all staff training log 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: 10/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2024


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 10/22/2024 01:39 PM - It Cannot Be Edited


Created By: Melody Brown On 10/22/2024 at 12:39 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: AUSTIN SMALL ARIZONA FAMILY HOME
FACILITY NUMBER: 331800219

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2024

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
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not developing the required Infection Control Plan that must be maintained at the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/28/2024
Plan of Correction
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Licensee stated to submit a copy of the required Infection Control Plan to LPA Brown on Plan of Correction (POC) due date.
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, interview and record review, the licensee did not comply with the section cited above by not ensuring that the facility regulated the hot water of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C) as evidenced of hot water measured at the facility during the visit at 76.4 degrees Fahrenheit which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/28/2024
Plan of Correction
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Licensee stated to regulate the hot water to not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C) 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: 10/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2024


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 10/22/2024 01:39 PM - It Cannot Be Edited


Created By: Melody Brown On 10/22/2024 at 12:39 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: AUSTIN SMALL ARIZONA FAMILY HOME
FACILITY NUMBER: 331800219

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2024

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 ensurimg that night lights were maintained in all hallways and passages to non-private bathrooms which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/28/2024
Plan of Correction
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Licensee showed night lights to be installed in hallways and passages to non-private bathrooms to LPA Brown during the visit. Plan of Correction (POC) cleared.
Type B
Section Cited
CCR
80072(4)
80072 Personal Rights (4) To be informed, and to have his/her authorized representative, if any, informed, by the licensee of the provisions of law regarding complaints including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency, and of information regarding confidentiality.

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 ensurimng that the CCLD Complaint Poster was posted in a common area which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/28/2024
Plan of Correction
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Licensee stated to download, print and post the complaint CCLD poster 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: 10/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2024


LIC809 (FAS) - (06/04)
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