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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880932
Report Date: 09/26/2024
Date Signed: 09/26/2024 11:33:45 AM

Document Has Been Signed on 09/26/2024 11:33 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:DAWSON HOMES INC. ON JEANNIE ANN CIRCLEFACILITY NUMBER:
331880932
ADMINISTRATOR/
DIRECTOR:		HAWTHORNE, ADINAFACILITY TYPE:
735
ADDRESS:7889 JEANNIE ANN CR.TELEPHONE:
(951) 898-7692
CITY:CORONASTATE: CAZIP CODE:
92880
CAPACITY: 4CENSUS: 3DATE:
09/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
11:40 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Raquel Hernandez and Mary Rico made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPAs met with Administrator Adina Hawthorne and was granted entry to the facility. The facility is a (4) bedroom, (2 and ½) bathroom home and with a kitchen/dining area, living room and attach garage. The facility is an Adult Residential Facility (ARF) level 3 designated home vendor by Inland Regional Center. Licensed capacity is (4) current census three (3). LPAs were accompanied by Facility Administrator Adina Hawthorne 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. However, LPAs observed a large amount of dog feces located in the backyard accessible to clients. Deficiency will be issued. The facility is maintained at a comfortable temperature. LPAs inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPAs observed sufficient furniture and lighting throughout the facility. The hot water temperature tested within regulation at 110 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, 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. All sharps are locked. There was a designated space for client/staff files.

Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a variety of food available for clients. Dishes, cups, and utensils were also stored properly.

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

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2024
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: DAWSON HOMES INC. ON JEANNIE ANN CIRCLE
FACILITY NUMBER: 331880932
VISIT DATE: 09/26/2024
NARRATIVE
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Record Review: LPA reviewed two (2) client files for admission agreements, updated physician reports, and needs and services plans. LPA reviewed two (2) client medications and P&I were reviewed. LPAs observed Client #1 (C1) PRN medication with the physician order not matching the Medication Administration Record (MAR). Also, LPAs observed expired PRN medication in both C1's and C2's PRN medication box. Deficiencies will be issued. LPA also reviewed two (2) staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings. LPAs observed Staff #1 (S1) did not have a transfer of criminal record clearance to the facility. Type A deficiency and Civil Penalty for $500 will be issued.

Based on the observations made during today’s visit, three deficiencies and one Civil Penalty LIC421BG were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809), (LIC809D), and LIC421BG was discussed and provided to Facility Administrator Adina Hawthrone.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/26/2024 11:33 AM - It Cannot Be Edited


Created By: Raquel Hernandez On 09/26/2024 at 10:35 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: DAWSON HOMES INC. ON JEANNIE ANN CIRCLE
FACILITY NUMBER: 331880932

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2024

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
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Based on observation, interview, record review, the licensee did not comply with the section cited by not ensuring that outside area was kept clean and sanitary due to dog feces, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2024
Plan of Correction
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Licensee stated to submit proof of removal of dog feces in backyard to LPA Hernandez by Plan of Correction (POC) due date.
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:Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/26/2024 11:33 AM - It Cannot Be Edited


Created By: Raquel Hernandez On 09/26/2024 at 10:44 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: DAWSON HOMES INC. ON JEANNIE ANN CIRCLE
FACILITY NUMBER: 331880932

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(5)(C)
80075 Health Related Services (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff desginated by the licensee shall be permitted to assist the client with self-administration, providing all of the following requirements are met: (C) A record of each dose is maintained in the client's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the client's response.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that Client #1 (C1) PRN medication matched the physician order on the Medication Administration Record (MAR) and Client #2 (C2) PRN medication being outdated, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2024
Plan of Correction
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Licensee stated to train all staff on medication administration and submit proof to LPA Hernandez on Plan of Correction (POC) due date.
Type A
Section Cited
CCR
80019(e)(3)
80019 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Saftey Code Section 1522 shall prior to working ...(3) Request a transfer of a criminal record clearance.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring Staff #1 (S2) had a transfer of a criminal record clearance to facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/27/2024
Plan of Correction
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Licensee stated to submit LIC9182 to LPA Hernandez by POC due date.
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:Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2024


LIC809 (FAS) - (06/04)
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