331880771-10-19-2023-56-AS-ACON-CWRQPE-20231019122037

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880771
Report Date: 10/19/2023
Date Signed: 10/19/2023 12:20:48 PM

Document Has Been Signed on 10/19/2023 12:20 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:	NISSI HOUSE		FACILITY NUMBER:	331880771
ADMINISTRATOR:	KNIGHTEN, CASSANDRA		FACILITY TYPE:	735
ADDRESS:	12801 EXCELSIOR ST		TELEPHONE:	(951) 378-3800
CITY:	WHITEWATER	STATE: CA	ZIP CODE:	92282
CAPACITY: 4		CENSUS: 2	DATE:	10/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:25 AM
MET WITH:	Kevin Hurd, Caregiver		TIME COMPLETED:	12:30 PM

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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Nissi House, Adult Residential Facility unannounced to conduct the facility's Annual Inspection. LPA was greeted and granted entry by Caregiver/Staff, Kevin. LPA singed in and was provided a space to work. Kevin Hurd accompanied LPA on a tour of the facility's interior and exterior.

The facility is comprised of 4 Bedrooms, 2 Bathrooms, Living Room, Dining Area, Kitchen, Backyard and attached garage. The facility is vendorized by the Inland Regional Center, designated Level 4I. Caregiver, reports there are two, (2) residents present and 1 resident out for the day with staff.

Physical Plant: The facility is licensed for four, (4) ambulatory adults. The facility is operating in the capacity approved by Community Care Licensing (CCL). Pathways interior and exterior were clutter free and unobstructed. The facility is maintained at 73 degrees temperature. The facility is equipped with functional smoke detectors and carbon monoxide alarms. Extra linens, hygiene supplies, toilet paper and towels were found in a hallway closet in sufficient amounts. Night-lights plugged up along the hallways provide sufficient lighting. Administrator reports fire/disaster drills are conducted twice a year along with the Facility Manager.

LPA observed resident rooms, each room included the regulated bed with linens, sufficient storage, furniture, lighting and seating. LPA observed sufficient furniture and adequate seating in the living and dining rooms. The hot water temperature tested and found within regulation. LPA observed posters for resident rights, Long Term Care Ombudsman, licensing documents, LET-US-KNOW and Infection Control, Resident/Staff Roasters posted in common areas of the facility. Cleaning supplies, toxins, sharps, and other dangerous items were kept secure under the kitchen sink and attached garage - inaccessible to residents. The resident's medication records and medications are kept secure in a cabinet next to the kitchen. Resident, Facility and Staff files are kept secure here as well.

Please see LIC809-C

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023

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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: NISSI HOUSE	FACILITY NUMBER: 331880771
	VISIT DATE: 10/19/2023

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Food Service: LPA observed a pantry and cabinets well stocked with canned goods, snacks and dry foods in good standing. LPA observed the facility refrigerator stocked with milk, eggs, break, water, frozen meals and juices. Sufficient amounts of both perishable and non-perishable food for the number of residents in care. Dishes, cups, and utensils were also observed and stored properly. LPA observed a fully charged fire extinguisher, last inspected May 16, 2023 near the kitchen Emergency Supplies of food, water, batteries, PPE were located in the attached garage.

Exterior (Backyard): at approximately 10:39am LPA observed the facility's backyard. LPA observed a broken screen laying on the ground, a portion of the facility perimeter fence blown over, a dismantled fire pit, 2 water hoses laid out, and 2 yard tools sitting out. At LPA's request Caregiver secured the yard tools and water hoses during the visit.. LPA was informed the projected completion date to get the fence and window screen fixed is within a week.

Records: LPA reviewed 3 resident files for admission agreements, updated physician reports, and needs and services plans. 2 out of 3 resident files contained outdated Physician's Reports, (LIC602). LPA reviewed two, (2) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. Each file was found to have all required licensing documents.

Based on observations, interviews and record reviews deficiencies will be cited per Title 22, California Code of Regulations to address the window screen and missing documentation. A copy of this report was read/reviewed with Facility Representative; signature acknowledges understanding and receipt of report and attachments.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 10/19/2023 12:20 PM - It Cannot Be Edited

Created By: Amber Coleman On 10/19/2023 at 12:00 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: NISSI HOUSE	FACILITY NUMBER: 331880771
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations of the facility's backyard the licensee did not comply with the section cited above by not ensuring the windows were secure with a screen in place and that the fire pit was removed once discovered dismantled; which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/20/2023
	Plan of Correction
1 2 3 4	Administrator/Licensee agrees to have the broken window screen replaced and send verification to the Community Care Licensing Office within 30 business days. The dismantled fire pit was removed and the yard tools secured during the visit.

Type B

Section Cited

CCR

85068.2(b)(1)(C)

Needs and Services Plan

(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (C) The written medical assessment specified in Section 80069. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations and record reviews, the licensee did not comply with the section cited above in two, (1) out of (3) resident files containing a blank Physician's Reports (LIC602) which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/20/2023
	Plan of Correction
1 2 3 4	Administrator/Licensee agrees to assist the resident in making and keeping an appointment with their Primary Care Physician to get their Physician's Reports completed.

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:

Nedra Brown

LICENSING EVALUATOR NAME:

Amber Coleman

LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 10/19/2023 12:20 PM - It Cannot Be Edited

Created By: Amber Coleman On 10/19/2023 at 12:00 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: NISSI HOUSE	FACILITY NUMBER: 331880771
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80069(b)

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. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations and record reviews, the licensee did not comply with the section cited above in two, (1) out of (3) resident files not containing a Physician's Reports (LIC602) which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/20/2023
	Plan of Correction
1 2 3 4	Administrator/Licensee agrees to assist the resident in making and keeping an appointment with their Primary Care Physician to get their Physician's Reports completed.

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:

Nedra Brown

LICENSING EVALUATOR NAME:

Amber Coleman

LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023

LIC809 (FAS) - (06/04)

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