331880819-3-17-2023-18-AS-CNWE-CPZTYS-20230317150912

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880819
Report Date: 03/17/2023
Date Signed: 03/17/2023 03:09:29 PM

Document Has Been Signed on 03/17/2023 03:09 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
RIVERSIDE, CA 92507

FACILITY NAME:	CALEB HOME		FACILITY NUMBER:	331880819
ADMINISTRATOR:	SAMANTHA PADILLA		FACILITY TYPE:	735
ADDRESS:	49252 PLUMA VERDE PLACE		TELEPHONE:	(760) 601-7307
CITY:	COACHELLA	STATE: CA	ZIP CODE:	92236
CAPACITY: 4		CENSUS: 3	DATE:	03/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:10 PM
MET WITH:	Brianna Ornelas, Lead Caregiver		TIME COMPLETED:	03:15 PM

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On March 17, 2023, Licensing Program Analysts (LPAs) Chinwe Nwogene and Kathleen Banrasavong arrived unannounced at the facility to conduct an annual inspection. LPAs was greeted and granted entry by caregiver, April Dominguez who was informed of the purpose of the visit. LPA also met with Administrator, Ericka Munoz who arrived at the facility shortly after. At the time of visit there was 4 staff and 2 residents present. LPAs toured the facility inside and out with April Dominguez.

Tour included:

Kitchen; LPAs toured the kitchen and observed kitchen to be clean and food is stored in a safe and healthful manner.

Dining and Livingroom; LPAs toured the dinning and Livingroom area. LPA observed area to be clean and furnitures in good condition. Temperature was 78 degrees Fahrenheit.

Hallway; LPAs toured the hallway and observed hallway to be clean with no pathway obstruction. LPA inspected the fire extinguisher and found it to be in compliance and record to be up to date. Carbon monoxide & smoke detector were tested and functioning properly. LPAs observed additional linens and hygiene items.

Medication; LPAs observed medications were labeled and stored in separate bins inside of a locked medication cabinet and are distributed according to physician orders. The first aid kit was complete.

Bathroom; LPAs toured 2 residents bathrooms and observed bathrooms to be clean and sanitary. There is also a good number of personal toiletries available for the residents in care. The hot water measured at 122 degrees Fahrenheit. LPA’s observed hot water warning signs posted at water taps.

Continue On LIC809-C

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2023

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 03/17/2023 03:09 PM - It Cannot Be Edited

Created By: Chinwe Nwogene On 03/17/2023 at 02:45 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: CALEB HOME	FACILITY NUMBER: 331880819
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80075(f)

Health-Related Services

(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by not having five staff not trained in first aid which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/27/2023
	Plan of Correction
1 2 3 4	The Administartor stated all staff will be trained in CPR and will provide picture of the certificate or card to LPA by the POC due date 3/27/2023.

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 record review, the licensee did not comply with the section cited above by not haveing physician report on file for resident #1 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/27/2023
	Plan of Correction
1 2 3 4	The Administartor stated a picture of resident #1 physician report will be emailed to LPA by POC due date 3/27/2023.

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:

Deborah Mullen

LICENSING EVALUATOR NAME:

Chinwe Nwogene

LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2023

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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CALEB HOME	FACILITY NUMBER: 331880819
	VISIT DATE: 03/17/2023

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Continued From LIC809

Bedroom/ staff room; LPAs toured four #4 out of #4 resident bedrooms and observed bedrooms to be clean and furnished according to regulation, which includes proper furniture, dressers, chairs and lighting. Night lights were maintained throughout the facility. LPAs toured the staff room and observed staff room to be clean and equipped with furnitures. LPAs observed staff bathroom to be clean and sanitary.

Garage; LPAs tour the garage and observed garage to be clean. LPAs observed knives adequately secured in a locked box. LPAs also observed cleaning solutions adequately secured in a cabinet in the garage.

Backyard; LPAs toured the backyard and observed backyard to be clean and furnitures in good condition. The backyard was free from obstruction and the side gate remain unlocked. No bodies of water was observed.

Food Services: There are seven days non-perishable and two days of perishable food supply present, and all food was properly stored and available to residents.

Records: All staff present have a criminal record clearance in file and are confirmed as being associated with the facility. Five #5 staff and three #3 residents' records were reviewed. During the review LPAs observed five staff has expired CPR certificate/ cards. Resident one #1 (R1) has no physician report on file. Two citations will be issued.

All required postings, including COVID’s postings, were posted near the entryway and throughout the facility. The administrator certificate expired on 3/7/2023. Administrator stated the Administrator application was sent on 3/6/2023 but the administrator certification has not been received yet.

Interview; Three staff and two residents present were interviewed.

Therefore, based on the observations made during today’s visit, two #2 deficiencies will be cited per Title 22, Division 6 of the California Code of Regulations. See LIC 809D. An exit interview was conducted, and this reported was provided along with appeal rights to Ericka Munoz.

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2023

LIC809 (FAS) - (06/04)

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