<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880909
Report Date: 06/28/2024
Date Signed: 06/28/2024 04:09:51 PM

Document Has Been Signed on 06/28/2024 04:09 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:VELASCO HOMEFACILITY NUMBER:
331880909
ADMINISTRATOR/
DIRECTOR:		SAENZ, ISAIAHFACILITY TYPE:
735
ADDRESS:51320 AVENIDA VELASCOTELEPHONE:
(760) 972-4355
CITY:LA QUINTASTATE: CAZIP CODE:
92253
CAPACITY: 4CENSUS: 4DATE:
06/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Nicole Lara, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA), Stephanie Martinez, made an unannounced visit to the facility for the purpose of conducting a required annual inspection. The LPA was greeted and allowed to enter the facility to conduct the inspection. On today’s visit the LPA met with Administrator, Nicole Lara; she was notified of the purpose for the visit.

PHYSICAL PLANT: The LPA inspected the interior and exterior areas of the facility. The LPA observed a black and pink substance to be lining the top of the shower tile and wall in the hall bathroom. LPA observed an empty soda bottle and a bread bag clip on the floor of the kitchen pantry. LPA observed dust on one to two kitchen cabinets, ceiling vents (3), the fire place cover, the wall above the fire place, and the curtain in the master bathroom. The LPA observed the walls and base boards in the living room, hallway and kitchen to have smudges and splatter of an unknown substance. A citation will be issued. The outdoor and indoor passageways were kept free of obstruction. No pool or body of water was observed on the property. According to the Administrator, there are no weapons kept in the home. Disinfectants, cleaning solutions, and poisons were inaccessible to clients in care. A comfortable temperature was being maintained in the home. There was sufficient lighting in all rooms to ensure the comfort and safety of clients. Toilets, hand washing and bathing facilities were kept safe and in operating condition. Additional equipment for physically handicapped clients is available. The smoke and carbon monoxide alarms were tested and found to be operable.
FOOD SERVICE: There was a variety of food which appeared to be selected and stored in a safe and healthful manner. Food supply of nonperishable and perishable foods was sufficient. The kitchen was observed to be clean.
RECORD REVIEW: Staff and client files were reviewed. First Aid/CPR training was observed on file for staff responsible for direct care. According to Administrator Lara, there are no clients in care with any restricted or prohibited health conditions. Staff present had the required criminal record clearances. An Individual Program Plan (IPP) and Medical Assessment (Physician's Report) was on file for client in care.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 06/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2024
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 3
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: VELASCO HOME
FACILITY NUMBER: 331880909
VISIT DATE: 06/28/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Administrator Lara has an active Administrator's certificate, which expires on 08/31/2026. A fire and earthquake drill was completed on 06/01/2024.
MEDICATION: Medications and medication storage areas were inspected. All medications were labeled and maintained in compliance with label instructions and State and Federal law. Medications were observed to be safe, locked, organized, and inaccessible to clients in care.

An exit interview was completed with Administrator Lara; this report was reviewed and a copy was provided, along with the LIC 811 and instructions on appeal rights.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 06/28/2024 04:09 PM - It Cannot Be Edited


Created By: Stephanie Martinez On 06/28/2024 at 03:35 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: VELASCO HOME
FACILITY NUMBER: 331880909

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. LPA observed a black and pink substance to be lining the top of the shower tile and wall in the hall bathroom. LPA observed an empty soda bottle and a bread bag clip on the floor of the kitchen pantry. LPA observed dust on one to two kitchen cabinets, ceiling vents (3), fire place cover, the curtain in the master bathroom, and wall above the fire place. LPA observed the walls and base boards in the living room, hall way and kitchen to have smudges and splatter of an unknown substance. This poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 07/31/2024
Plan of Correction
1
2
3
4
Administrator stated all physical plant concerns listed above would be addressed and photos would be submitted as proof.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2024


LIC809 (FAS) - (06/04)
Page: 3 of 3