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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880782
Report Date: 10/06/2023
Date Signed: 10/06/2023 11:39:00 AM

Document Has Been Signed on 10/06/2023 11:39 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:MIMOSA HIGHPOINTEFACILITY NUMBER:
331880782
ADMINISTRATOR:STEWART, LEONAFACILITY TYPE:
735
ADDRESS:15160 MIMOSA DRTELEPHONE:
(562) 682-0946
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92530
CAPACITY: 4CENSUS: 3DATE:
10/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Maureen Sevilla - House ManagerTIME COMPLETED:
11:48 AM
NARRATIVE
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Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection LPA met with House Manager Maureen Sevilla was granted entry to the facility. At the time of the visit there were three (3) staff present and zero (0) clients present. The clients were away at their day programs.

The facility is a four (4) bedroom, two (2) bathroom home with a kitchen/dining area, living room, and attached garage. The facility is an Adult Residential Facility (ARF) level 4i home vendorized by Inland Regional Center. The facility is licensed for a capacity of four (4) clients and the current census is three (3) clients. LPA was accompanied by House Manager to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperatures in the bathroom to be at 142.5 degrees F. The water temperature is not within the required temperature of 105 F and 120 F. The facility will be issued a type B deficiency as well as a technical violation. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, labor laws, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. There was a designated storage space for client/staff files. Medications are kept inside medication closet inaccessible to clients. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2023
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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Document Has Been Signed on 10/06/2023 11:39 AM - It Cannot Be Edited


Created By: Ryan Gardner On 10/06/2023 at 10:40 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
RIVERSIDE, CA 92507

FACILITY NAME: MIMOSA HIGHPOINTE
FACILITY NUMBER: 331880782

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)
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:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, document review, and observation the licensee did not comply with the section cited above evidenced by allowing Staff S1 to work at the facility for ten (10) months without an approved criminal record clearance which poses an immediate health, safety, or personal rights risk to persons in care.
POC Due Date: 10/07/2023
Plan of Correction
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The licensee has agreed to read regulation 80019 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to not allow S1 to work at the facility until they are granted an approved criminal record clearance. The POC due date of 10/7/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Ryan Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/06/2023 11:39 AM - It Cannot Be Edited


Created By: Ryan Gardner On 10/06/2023 at 10:40 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
RIVERSIDE, CA 92507

FACILITY NAME: MIMOSA HIGHPOINTE
FACILITY NUMBER: 331880782

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and observation the licensee did not comply with the section cited above evidenced by having the water in the bathroom sink at a temperature of 142.5 F which poses a potential health, safety, or personal rights risk to persons in care.
POC Due Date: 10/07/2023
Plan of Correction
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The licensee has agreed to read regulation 80088 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to adjust the water heater within the required temperature by the POC due date of 10/7/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Ryan Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2023


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: MIMOSA HIGHPOINTE
FACILITY NUMBER: 331880782
VISIT DATE: 10/06/2023
NARRATIVE
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Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPA reviewed three (3) client files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings. It was revealed that Staff S1 has been working at the facility for ten (10) months without an approved criminal record clearance. The facility will be issued a type A deficiency as well as a $500-dollar civil penalty for allowing S1 to work at the facility. Medications/MARs records were audited and appeared to be dispensed appropriately by staff members.

Based on the observations made during today’s visit, two (2) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations, as well as a $500-dollar civil penalty.

An exit interview was conducted, and this report (LIC809), LIC809D forms, LIC421BG form, LIC811 form, LIC9102, and appeal rights were discussed and provided to House Manager Maureen Sevilla.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023
LIC809 (FAS) - (06/04)
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