331880710-3-8-2023-18-AS-JARA-CPQT5Y-20230308132616

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880710
Report Date: 03/08/2023
Date Signed: 03/08/2023 01:26:39 PM

Document Has Been Signed on 03/08/2023 01:26 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
RIVERSIDE, CA 92507

FACILITY NAME:	BALLENTINE RESIDENTIAL CARE		FACILITY NUMBER:	331880710
ADMINISTRATOR:	RYAN SHERMAN		FACILITY TYPE:	735
ADDRESS:	40154 TENNYSON RD		TELEPHONE:	(951) 397-3916
CITY:	MURRIETA	STATE: CA	ZIP CODE:	92563
CAPACITY: 4		CENSUS: 4	DATE:	03/08/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Staff, Allison Sherman		TIME COMPLETED:	01:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit on 3/8/2023 at 09:45 a.m. LPA was granted entry and met with staff Allison Sherman who was informed of the purpose of the visit. At the time of the visit there was (1) client and (3) staff present.

The facility is a one story home with (4) bedrooms and (2) bathrooms for clients. 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 staff and client interviews. LPA observed the following:

Infection Control: The LPA observed the hand washing stations in the facility. . LPA observed gloves and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's mitigation plan and found all required infection control measures. LPA will issue type b deficiency for facility not being able to provide a copy of their infection control plan during the visit. Deficiency and plan of correction was documented for this.

Physical Plant: LPA observed the client bedrooms. Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. There is an adequate number of activity. The outdoor area was observed to have a shaded area for clients and was free of hazards. laundry room. LPA observed (1) of the client restrooms to have an unclean toilet. The LPA was informed by staff that the client receives prompts to clean their private restroom. LPA will document a technical advisory note for facility to maintain client restrooms in clean and sanitary condition.

Operating Requirements: The facility has secured a fire clearance that is for 4 ambulatory clients only.

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. LPA observed non-perishables in the facility garage.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023

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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BALLENTINE RESIDENTIAL CARE	FACILITY NUMBER: 331880710
	VISIT DATE: 03/08/2023

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Care & Supervision/Administration: Adequate staff are present for the supervision of residents. Emergency exiting plans, telephone numbers and personal rights were found posted in the facility. The listed administrator, possesses a current administrator's certificate.

Record Review and Resident/Staff Files: LPA reviewed (2) staff files and reviewed the facility's staff schedule. All other staff have criminal clearance and updated training along with CPR/First Aid Certification. Two (2) client files were reviewed, and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: All client medication was locked in a medication room. LPA reviewed client medications for (2) clients and found all medication listed on centrally stored lists and all required labeling was found to be in place.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing the facility last fire and earthquake drills, which met the department requirements. LPA observed all facility exits were clear from obstructions.

An exit interview was conducted where a copy of this report along with LIC 809-D pages and appeal right were provided to staff, Allison Sherman.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/08/2023 01:26 PM - It Cannot Be Edited

Created By: Janira Arreola On 03/08/2023 at 01:12 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: BALLENTINE RESIDENTIAL CARE	FACILITY NUMBER: 331880710
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/08/2023

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
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above with infection control that was not present during the time of the visit. This posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/15/2023
	Plan of Correction
1 2 3 4	Licensee agreed to send LPA the infection control plan by the POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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:

Joel Esquivel

LICENSING EVALUATOR NAME:

Janira Arreola

LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023

LIC809 (FAS) - (06/04)

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