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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880771
Report Date: 06/18/2024
Date Signed: 06/18/2024 01:30:20 PM

Document Has Been Signed on 06/18/2024 01:30 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:NISSI HOUSEFACILITY NUMBER:
331880771
ADMINISTRATOR/
DIRECTOR:		KNIGHTEN, CASSANDRAFACILITY TYPE:
735
ADDRESS:12801 EXCELSIOR STTELEPHONE:
(951) 378-3800
CITY:WHITEWATERSTATE: CAZIP CODE:
92282
CAPACITY: 4CENSUS: 4DATE:
06/18/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:17 AM
MET WITH:Licensee Cassandra Knighten and House Manager Nadiyah SingletonTIME VISIT/
INSPECTION COMPLETED:
01:37 PM
NARRATIVE
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On 06/18/2024 at 09:17 AM, Licensing Program Analyst (LPA) Melody Brown met with Staff #2 (S2) to initiate a Case Management Visit. The investigation consisted of observation, interviews, and a review of pertinent documentation.

During the facility visit on 06/18/2024, Licensing Program Analyst (LPA) Melody Brown requested Client #1 (C1) facility file to review documents and LPA Brown observed that C1 does not have Physician Report (LIC602)/Medical Assessment on C1’s facility file. Administrator Cherron Jackson arrived and LPA Brown informed Administrator Jackson that C1 does not have Medical Assessment or Physician Report (LIC602) in C1 facility file. LPA Brown explained to Administrator Jackson and S2 that deficiency will be issued as in Adult Residential Facility (ARF), the Licensee must obtain and keep on file documentation of the client’s medical assessment prior to accepting client into care. Administrator Jackson and S2 verbalized understanding. Licensee Cassandra Knighten and House Manager Nadiyah Singleton arrived during the visit and reported to LPA Brown that they will provide a copy of C1 Medical Assessment once it's available. Also Licensee Knighten and House Manager Singleton reported that C1 was placed at the facility on 06/30/2020 by Inland Regional Center (IRC).

Moreover, during the quick tour of the facility, LPA Brown observed five (5) knives in the kitchen drawer and one (1) knife in the kitchen sink, not locked and accessible to clients in care. Deficiency will be issued. Also, LPA Brown observed multiple bottles of chemicals under the kitchen sink not locked and accessible to clients in care. Deficiency will be issued. To add to that, client medications were observed not locked and accessible to clients in care, deficiency will be issued.

*** Continuation on LIC809C ***

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2024
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 5
Document Has Been Signed on 06/18/2024 01:30 PM - It Cannot Be Edited


Created By: Melody Brown On 06/18/2024 at 12:05 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: NISSI HOUSE
FACILITY NUMBER: 331880771

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/19/2024
Section Cited
CCR
80087(g)

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80087 Buildings 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:
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Licensee immediately locked the five (5) knives in the kitchen drawer and removed the one (1) knife in the kitchen sink and also locked it during the visit. Plan of Corection (POC) cleared.
Licensee stated to train all staff on CCR 80087(g) and submit proof of staff training to LPA Brown on POC due date.
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not locking the five (5) knives in the kitchen drawer and one (1) knife in the kitchen sink, which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
06/19/2024
Section Cited
CCR80087(g)(1)

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80087 Buildings 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. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.
This requirement is not met as evidenced by:
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Licensee immediately locked the multiple bottles of chemicals under the kitchen sink during the visit. POC cleared.
Licensee stated to train all staff on CCR 80087(g)(1) and submit proof of all staff training log to LPA Brown on POC due date.
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not locking multiple bottles of chemicals under the kitchen sink making it accessible to clients in care which poses an immediate health, safety and personal rights risks to clients in care.
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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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 06/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/18/2024 01:30 PM - It Cannot Be Edited


Created By: Melody Brown On 06/18/2024 at 12:22 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: NISSI HOUSE
FACILITY NUMBER: 331880771

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/30/2024
Section Cited
CCR
80019(e)(3)

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80019 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 80019(f) or This requirement is not met as evidenced by:
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Licensee stated to transfer S2 and S3 criminal background clearance to the facility and submit proof to LPA Brown on Plan of Correction (POC) due date.
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Based on observation, interview, record review, the licensee did not comply with the section cited above by not transferring Staff #2 (S2) and Staff #3 (S3) criminal background clearance to the facility prior to employmeny which poses a potential health, safety and personal rights risks to clients in care.
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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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 06/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/18/2024 01:30 PM - It Cannot Be Edited


Created By: Melody Brown On 06/18/2024 at 12:36 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: NISSI HOUSE
FACILITY NUMBER: 331880771

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/19/2024
Section Cited
CCR
80069(b)

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80069 Client Medical Assessment (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:
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LIcensee stated to obtain Client #1 Medical Assessment or submit proof of Medical Appointment to obtain C1 Medical Assessment to LPA brown on Plan of Correction (POC) due date.
Licensee stated to submit Signed Statement of Understanding on CCR 80069(b) to LPA Brown on POC due date.
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Based on interview, observation and records review, the Licensee did not comply with the section cited above by not obtaining and keeping on file documentation of Client #1 (C1) medical assessment prior to accepting C1 at the facility on 06/30/2020 which poses immediate health, safety and personal rights risks to clients in care.
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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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 06/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
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: 06/18/2024
NARRATIVE
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LPA Brown observed that Staff #2 (S2) and Staff #3 (S3) have their criminal background clearance but the facility did not transfer their croiminal background clearance prior to employment and S2 reported to LPA Brown that S2 started working at the facility on 02/2024 and S3 reported working at the facility since 2018. Deficiencies will be issued.

During today's visit, the facility will be cited for civil penalty of $500.00 per individual for not transferring S2 and S3 criminal background clearance prior to employment and will continue to be assessed of $100.00/day until corrected.

An exit interview was conducted where this report (LIC809), LIC809D, LIC421BG and Appeal Rights were discussed and provided Licensee Cassandra Knighten and Administrator Nadiyah Singleton

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

DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024
LIC809 (FAS) - (06/04)
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