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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880771
Report Date: 11/25/2024
Date Signed: 11/25/2024 11:43:27 AM

Document Has Been Signed on 11/25/2024 11:43 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/
DIRECTOR:		KNIGHTEN, CASSANDRAFACILITY TYPE:
735
ADDRESS:12801 EXCELSIOR STTELEPHONE:
(951) 378-3800
CITY:WHITEWATERSTATE: CAZIP CODE:
92282
CAPACITY: 4CENSUS: 4DATE:
11/25/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Cherron JacksonTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
NARRATIVE
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On 11/25/2024 at 09:15 AM, Licensing Program Analyst (LPA) Melody Brown arrived at the facility unannounced to initiate a Case Management Visit. The investigation consisted of observation, interviews, and a review of pertinent documentation. LPA Brown met with Client #2 (C2) and C2 reported to LPA Brown that there's no staff at the facility during the visit. LPA Brown contacted Licensee Cassandra Knighten and informed of the visit. Staff Cherron Jackson arrived at the facility at around 10:27 AM.

During the visit today, 11/25/2024, LPA Brown contacted Licensee Knighten and informed Licensee Knighten that there should be a staff at the facility to provide care and supervision for C2. LIcensee Knighten verbalilzed understanding. In addition, LPA Brown explained to staff Jackson that C2 cannot be left alone and without staff available to provide care and supervision. Also, LPA Brown informed staff Jackson that deficiency will be issued with $500.00 immediate Civil Penalty is assessed as this citation is a zero tolerance and poses immediate risk to clients in care. LPA Brown also added that an informal meeting will be scheduled at the regional office.

An exit interview was conducted with staff Cherron Jackson and a copy of this report (LIC809), LIC 809D, LIC421IM and Appeal Rights were discussed and provided.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/25/2024
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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Document Has Been Signed on 11/25/2024 11:43 AM - It Cannot Be Edited


Created By: Melody Brown On 11/25/2024 at 10:19 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: 11/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/26/2024
Section Cited
CCR
80065(a)

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80065 Personnel Requirements (a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.
This requirement is not met as evidenced by:
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Licensee stated to train all staff on CCR 80065(a) and submit proof of all staff training log to LPA Brown on Plan of Correction (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 ensuring that there's a staff at the facility to care and supervise for Client #2 (C2) which poses an immediate health, safety or personal rights risk to persons 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: 11/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/25/2024


LIC809 (FAS) - (06/04)
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