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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880819
Report Date: 02/21/2024
Date Signed: 02/21/2024 12:57:11 PM

Document Has Been Signed on 02/21/2024 12:57 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:CALEB HOMEFACILITY NUMBER:
331880819
ADMINISTRATOR:SAMANTHA PADILLAFACILITY TYPE:
735
ADDRESS:49252 PLUMA VERDE PLACETELEPHONE:
(760) 601-7307
CITY:COACHELLASTATE: CAZIP CODE:
92236
CAPACITY: 4CENSUS: 4DATE:
02/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Stephanie Olivas - AdministratorTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of conducting the annual inspection. LPA Colvin met with Administrator Stephanie Olivas and informed her of the purpose of today's inspection. Below is a summary of what was observed:

Infection Control: LPA Colvin observed that the facility has an updated Infection Control Plan on file and is demonstrating best practices in the facility to maintain a healthy environment for staff and residents. Such measures include: soap and paper towels at hand washing stations, trash cans with tight-fitting lids, and monitoring the residents and staff for symptoms of infectious diseases.

Physical Plant: LPA Colvin toured the facility and observed that there a sufficient bedrooms and bathrooms for both staff and residents. LPA Colvin observed the required furniture and linen to be present and in good condition in resident bedrooms. LPA Colvin observed the facility to be a comfortable temperature. LPA Colvin measured the hot water in three bathroom faucets, and obtained readings of 103.1 degrees (downstairs) and 119.6 degrees (upstairs). Hot water is to be between 105 and 120 degrees. Deficiency cited. LPA Colvin did not observe any obstructions to emergency exits or hallways/walkways. LPA Colvin tested the facility's carbon monoxide alarm and smoke detectors and found them to be operational. LPA Colvin observed that sharp objects like knives and dangerous chemicals were locked in a safe in the locked garage, away from residents' reach.
Operational Requirements: LPA Colvin observed the facility to be operating within their licensed capacity of 3 ambulatory and 1 non-ambulatory resident.

Staffing & Staff Records: LPA Colvin confirmed that there are sufficient staff present to meet the needs of residents. LPA Colvin additionally confirmed that there is a certified Administrator present. LPA Colvin confirmed staff have criminal record clearance and have training to perform their required duties. Staff present have current CPR/First Aid Certification and have other relevant training listed in their files.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2024
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 02/21/2024 12:57 PM - It Cannot Be Edited


Created By: Crystal Colvin On 02/21/2024 at 12:21 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: 02/21/2024

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 observation, the licensee did not comply with the section cited above in 1 out of 3 bathroom faucets, which poses a potential health, safety or personal rights risk to persons in care. LPA Colvin measured the hot water in the downstairs bathroom to be measuring at 103.1 degrees.
POC Due Date: 03/06/2024
Plan of Correction
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Administrator stated that they will have a professional come out and take a look at the hot water heater and conduct additional readings of the tempuratures to make neccesary adjustments to ensure hot water is within correct range at all faucets. Administrator to provide LPA Colvin with receipt of service by Plan of Correction date of 3/6/24.
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:Rikesha Stamps
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2024


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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CALEB HOME
FACILITY NUMBER: 331880819
VISIT DATE: 02/21/2024
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Resident Records: LPA Colvin reviewed the files for all 4 current residents to confirm that they have the required information present in their files, including Physician's Report, Admissions Agreement, and current Needs & Services Plan. LPA Colvin interviewed 3 of 4 residents at the facility and additionally reviewed medications and did not observe any concerns during today's inspection.

Food Services: LPA Colvin observed the facility to have the required amount of perishable and non-perishable food. LPA Colvin observed the kitchen and dining area to be maintained in a clean and healthful manner. Sufficient dishware and silverware was present for residents use.

Incidental Medical Services: LPA Colvin observed that resident medication is locked in a cabinet in the kitchen and inaccessible to residents. LPA Colvin confirmed that the facility is not retaining any residents with prohibited health conditions.

Emergency Disaster Preparedness: LPA Colvin confirmed that the facility has an Emergency Disaster Plan on file and conducts regular Emergency Disaster drills.

An exit interview was conducted with Administrator Stephanie Olivas and a copy of this report, LIC9098 (Proof of Correction Form), LIC809D, and appeal rights were provided.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024
LIC809 (FAS) - (06/04)
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