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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880621
Report Date: 05/16/2024
Date Signed: 05/16/2024 12:58:21 PM

Document Has Been Signed on 05/16/2024 12:58 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:FAMILY LEGACY RESIDENTIAL FACILITYFACILITY NUMBER:
331880621
ADMINISTRATOR/
DIRECTOR:		BADER, IVY TFACILITY TYPE:
735
ADDRESS:34847 MIDDLECOFF CTTELEPHONE:
(949) 413-0891
CITY:BEAUMONTSTATE: CAZIP CODE:
92223
CAPACITY: 4CENSUS: 3DATE:
05/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Ivy Bader - LicenseeTIME VISIT/
INSPECTION COMPLETED:
01:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced required 1-year visit to the facility. LPA met with Ivy Bader, Licensee, and discussed the purpose of the visit.

The facility is a level (2), Adult Residential Facility (ARF) and is an Inland Regional Center (IRC) certified vendor. LPA conducted an overall inspection of the facility, which included, but was not limited to the following:

Operation/Physical Plant: The facility has a fire clearance for four (4) ambulatory clients and a current census of three (3) clients. The facility has a infection control plan and client registry list on file. The facility has no swimming pools or similar bodies of water. The facility's outdoor activity space is gated and has sufficient shaded space for client activities. The facility’s indoor space is sufficient for client activities and passageways were kept free of obstruction. The facility has sufficient lighting and is maintained at a comfortable temperature. The facility is equipped with operating laundry equipment, fire/carbon monoxide alarms and telephone service. The facility has sufficient supply of bed linen, towels, hygiene products and activity supplies for clients in care. The facility has posted in a common area client personal rights, house rules, Community Care Licensing Complaint poster, and disaster evacuation plan. Client bedrooms were equipped with beds, bed linen, chairs, night stands, sufficient storage space and lighting. Client toilets, hand washing and bathing facilities were operating in safe and sanitary conditions. The hot water in client bathrooms tested at 107- and 116- degrees F. Deficiencies cited: the facility's backyard passageway had overgrown pomegranate foliage and outdoor furniture blocking passageway clearance.

Food Service: The facility has sufficient non-perishable and perishable food for number of clients in care. The facility’s freezers were maintained at a temperature of zero degrees. The facility’s refrigerators were maintained at a temperature of 44 degrees F. The facility has sufficient cups, plates, and utensils for client use.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: FAMILY LEGACY RESIDENTIAL FACILITY
FACILITY NUMBER: 331880621
VISIT DATE: 05/16/2024
NARRATIVE
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Health Related Services: All client medications are labeled and centrally stored in a locked cabinet inaccessible to clients in care. The facility has a first aid kit and manual.

Personnel/Client Records: The Licensees' Administrator's certification expires on 2/14/2026. Three (3) staff files were reviewed for CPR/first aid training, job training, employment applications, criminal record clearances, and health screenings. Three (3) client files were reviewed for admissions agreements, needs and services plans, physician's reports/assessments, personal rights, and personal and incidental (P&I) ledgers. Deficiencies cited: LPA observed Client #1(C1) and Client #2 (C2) did not have a current annual needs and service plan on file. LPA observed Client #3 (C3) did not have a physician's report/medical assessment on file.

Based on LPA observations and record review, deficiencies were cited per Title 22, of The California Code of Regulations.



This report, deficiencies, and correction plans were reviewed with the Licensee and copies with Appeal Rights were provided and the conclusion of the visit.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024
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Document Has Been Signed on 05/16/2024 12:58 PM - It Cannot Be Edited


Created By: Magda Malcore On 05/16/2024 at 12:01 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: FAMILY LEGACY RESIDENTIAL FACILITY
FACILITY NUMBER: 331880621

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations, the licensee did not comply with the section cited above overgrown pomegranate tree and outdoor furniture blocking passageway clearance, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2024
Plan of Correction
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By POC due date, the Licensee shall submit to the licensing agency documentation of cleared passageways.
Section Cited
Personnel Records
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:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2024


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 05/16/2024 12:58 PM - It Cannot Be Edited


Created By: Magda Malcore On 05/16/2024 at 12:01 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: FAMILY LEGACY RESIDENTIAL FACILITY
FACILITY NUMBER: 331880621

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Personnel Records
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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2
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4
Type B
Section Cited
CCR
80068.3(a)
Modifications to Needs and Services Plan
(a) The licensee shall ensure that each client's written Needs and Services Plan is updated as often as necessary to assure its accuracy, but at least annually. These modifications shall be maintained in the client's file.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's record review, the licensee did not comply with the section cited above by not maintaining Client #1 (C1s) and Client #2 (C2s) current annual needs and service plan on file for review, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2024
Plan of Correction
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By POC due date, the Licensee shall submit to the Licensing Agency C1's and C2's needs and service plan.
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:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2024


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 05/16/2024 12:58 PM - It Cannot Be Edited


Created By: Magda Malcore On 05/16/2024 at 12:01 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: FAMILY LEGACY RESIDENTIAL FACILITY
FACILITY NUMBER: 331880621

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Client Medical Assessments
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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4
Type B
Section Cited
CCR
80069(b)(1)
Client Medical Assessments
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment. (1) Such assessment shall be performed by a licensed physician, or designee, who is also a licensed professional, and the assessment shall not be more than one year old when obtained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review, the licensee did not comply with the section cited above by not maintaining a physician's report/medical assessment for Client #3 (C3) on file for review, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2024
Plan of Correction
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By POC due date, the Licensee shall submit to the Licensing Agency documentation of C3s medical assessment.
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:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2024


LIC809 (FAS) - (06/04)
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