<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880771
Report Date: 07/14/2022
Date Signed: 07/14/2022 11:58:11 AM

Document Has Been Signed on 07/14/2022 11:58 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:NISSI HOUSEFACILITY NUMBER:
331880771
ADMINISTRATOR:KNIGHTEN, CASSANDRAFACILITY TYPE:
735
ADDRESS:12801 EXCELSIOR STTELEPHONE:
(951) 378-3800
CITY:WHITEWATERSTATE: CAZIP CODE:
92282
CAPACITY: 4CENSUS: 2DATE:
07/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Joshua Kevin Hurd- Support Staff TIME COMPLETED:
12:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Bernadette Allen made an unannounced visit to the facility to conduct an annual inspection focused on infection control. At 10:30 AM, LPA was greeted and granted entry into the facility by Joshua Kevin Hurd support staff and he was informed of the purpose of the visit. At the time of visit there was 1 staff and 2 residents present. The facility currently has zero positive or suspected Covid-19 cases.

During today's visit, LPA toured the facility and made observations regarding the infection control measures that the facility has implemented. LPA observed Covid-19 postings posted throughout the facility. The facility has an adequate amount of hand hygiene supplies (soap, hand sanitizer). The staff were also observed wearing appropriate face coverings (surgical masks) at the time of visit.

The facility staff has a plan to manage Covid-19 symptoms, which includes staff monitoring residents regularly for any changes in condition, which includes daily temperature checks. The facility will contact the resident's physician should there be event of any COVID-19 related illnesses. The facility staff are responsible for cleaning and disinfecting the highly touched surfaces during their shift.

LPA toured the facility inside and out and there were no health and safety concerns. The outdoor and indoor hallways were also free of obstruction.

The clients rooms had the required furniture and sufficient lighting. The bathrooms can accommodate the needs for bathing and showers and have non-slip flooring. The facility had a supply of additional linen and extra hygiene items for the clients. LPA measured the hot water temperature at degrees 105.6 F. LPA observed hand sanitizer throughout the facility and a 30- day supply of PPE. The facility has charged fire extinguishers, operating smoke alarms, and carbon monoxide detectors at the facility.

Continued

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE: DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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: NISSI HOUSE
FACILITY NUMBER: 331880771
VISIT DATE: 07/14/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
During the tour, LPA confirmed that Staff had criminal record clearances but was not associated to the facility. This poses an immediate health & safety risk to the clients in care. LPA was informed that S1 has worked at this facility since 6/22/2020. A civil penalty of $500 was assessed on 7/14/2022.

Refer to LIC809D for deficiency cited. An exit interview was conducted where this report, LIC809D was provided to Joshua Kevin Hurd- Support Staff.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 07/14/2022 11:58 AM - It Cannot Be Edited


Created By: Bernadette Allen On 07/14/2022 at 11:28 AM
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: NISSI HOUSE
FACILITY NUMBER: 331880771

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
87355(e)(1)


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
During the tour, LPA confirmed that Staff had criminal record clearances but was not associated to the facility. This poses an immediate health & safety risk to the clients in care. LPA was informed that S1 has worked at this facility since 6/22/2020. A civil penalty of $500 was assessed on 7/14/2022
POC Due Date: 07/15/2022
Plan of Correction
1
2
3
4
Licensee with associate throgh gardian system by 7/15/2022
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:Karen Clemons
LICENSING EVALUATOR NAME:Bernadette Allen
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2022


LIC809 (FAS) - (06/04)
Page: 3 of 3