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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881097
Report Date: 06/01/2023
Date Signed: 06/06/2023 09:41:54 AM

Document Has Been Signed on 06/06/2023 09:41 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ABC 2 ,LLCFACILITY NUMBER:
331881097
ADMINISTRATOR:PROTHRO, ESTERFACILITY TYPE:
735
ADDRESS:25320 IVORY AVETELEPHONE:
(951) 442-5952
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY: 3CENSUS: 2DATE:
06/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Caregiver Anthony SmithTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janette Romero and Licensing Program Manager (LPM) Joel Esquivel conducted an unannounced annual required visit on 6/1/2023 at 9:25 a.m. LPM and LPA were granted entry and met with Caregiver Anthony Smith who was informed of the purpose of the visit. Administrator Esther Prothro arrived at 9:50 a.m. At the time of the visit there were (1) staff and (1) client present.

The facility is made up of a two-story home with (3) bedrooms and (2) bathrooms with an attached garage. No pools or firearms are being kept at the facility. The clients served are adults between the ages of 18-59. LPM and LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted a staff interview. LPM and LPA observed the following:

Infection Control: LPM and LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPM and LPA reviewed staff records and found that all staff had infection control training. First aid kit was complete. LPM and LPA observed a soiled hygiene kit under the restroom sink assigned to Client 2 (C2).



Physical Plant: LPM and LPA observed the client bedrooms. Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture in good repair were present. The outdoor area was observed to be free of hazards. LPM and LPA observed outdoor furniture and shaded area for clients. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to clients in a locked closet. The smoke detector and carbon monoxide were operational, and the hot water temperature measured 112F.

Continued on 809-C..
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/01/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ABC 2 ,LLC
FACILITY NUMBER: 331881097
VISIT DATE: 06/01/2023
NARRATIVE
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Food Service: LPM and LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPM and LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods, with emergency food supplies stored in the garage.

Care & Supervision/Administration: Adequate staff are present for the supervision of clients during the visit. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility.

Centrally Stored Medications: When LPM and LPA entered the facility, the medication cabinet was observed unlocked. Caregiver Smith immediately secured the medication cabinet with a lock. While touring the second story floor of the facility, which serves as a staff office, LPM and LPA observed accessible medication labeled Ondansetron Orally Disintegrating Tablets 4mg along with several boxes of diabetic lancets assigned to Client 1 (C1). LPA observed unlabeled medication in C1's medication container.

Employee Clearance/Association: LPM and LPA observed Caregivers Smith, Stephan Rochelle and LaToya Mcclain are not associated to the facility.

During this visit, LPA found the following deficiencies faulting the facility:

80075(k)(1)

80075(b)

80075(k3)

80019(f)

This report was discussed with Adminitrator Prothro and a copy of this report was provided to the Administrator Prothro along with Appeal Rights.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 06/06/2023 09:41 AM - It Cannot Be Edited


Created By: Janette Romero On 06/01/2023 at 12:53 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: ABC 2 ,LLC
FACILITY NUMBER: 331881097

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(f)
(f) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from TrustLine to a state licensed facility by providing the following documents to the Department:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in 3 out of 4 staff, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2023
Plan of Correction
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Licensee agreed to provide proof of association to CCLD by close of business on 6/2/2023.
Type A
Section Cited
CCR
80075(b)
Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in 1 of 2 clients were not provided prescribed medication as ordered by physician, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2023
Plan of Correction
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Licensee agreed to provide proof of medication refill for client in question to CCLD by close of business on 6/2/2023.
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:Joel Esquivel
LICENSING EVALUATOR NAME:Janette Romero
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 06/06/2023 09:41 AM - It Cannot Be Edited


Created By: Janette Romero On 06/01/2023 at 01:10 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: ABC 2 ,LLC
FACILITY NUMBER: 331881097

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(1)
(k) The following requirements shall apply to medications which are centrally stored:

(1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation and interview, the licensee did not comply with the section cited above by leaving medication cabinet unlocked and accessible to clients, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2023
Plan of Correction
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Licensee agreed to provide staff training regarding maintaining medication inaccessible to clients to CCLD by close of business on 6/2/2023.
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:Joel Esquivel
LICENSING EVALUATOR NAME:Janette Romero
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2023


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 06/06/2023 09:41 AM - It Cannot Be Edited


Created By: Janette Romero On 06/01/2023 at 01:15 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: ABC 2 ,LLC
FACILITY NUMBER: 331881097

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(k)(3)
(k) The following requirements shall apply to medications which are centrally stored:

(3) All medications shall be labeled and maintained in compliance with label instructions and state and federal laws.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by having an unlabeled medication bottle in a client's medication container, belonging to a staff, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2023
Plan of Correction
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Licensee agreed to provide staff training on how to review and maintain proper labeling of medication for both staff and clients. Proof of training will be provided to CCLD by close of business on 6/2/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Joel Esquivel
LICENSING EVALUATOR NAME:Janette Romero
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2023


LIC809 (FAS) - (06/04)
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