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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881099
Report Date: 08/21/2024
Date Signed: 08/21/2024 03:30:59 PM


Document Has Been Signed on 08/21/2024 03:30 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:RODRIGUEZ FAMILY HOMEFACILITY NUMBER:
331881099
ADMINISTRATOR:IVETTE MUNOZFACILITY TYPE:
735
ADDRESS:11878 RIDGECREST DRTELEPHONE:
(951) 858-5709
CITY:RIVERSIDESTATE: CAZIP CODE:
92505
CAPACITY:2CENSUS: 2DATE:
08/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Licensee/ Administrator Ivette Munoz
TIME COMPLETED:
03:40 PM
NARRATIVE
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On 08/21/2024 at 12:30 PM LPAs Lavette Farlow, Melody Brown, and Becky Mann conducted unannounced visit to the facility to conduct the required annual inspection to the facility. LPAs Farlow, Brown and Mann were greeted and gained access at the home by Licensee/Administrator Ivette Munoz. LPAs Farlow, Brown and Mann explained the purpose of the visit to Licensee/Administrator Munoz.

The facility has five (5) bedrooms, two (2) bathooms, kitchen, dining room, living room, attached garage, and backyard. The facility is vendorized by Inland Regional Center (IRC). LPAs Farlow, Brown and Mann completed a walkthrough of the facility, review of records, and medications audit .



Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD), LPAs Farlow, Brown and Mann observed two (2) clients during the visit. There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 71 degrees Fahrenheit. LPAs Farlow, Brown and Mann inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting. LPAs Farlow, Brown and Mann inspected client bathrooms; bathrooms were clean, and appliances were found functional. Water temperatures tested at 118.5 degrees Fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide detectors, charged fire extinguisher, and first aid kit with first aid book.

Posters such as; the personal rights, CCLD complaint poster, and emergency disaster plan were posted in a common area. Client medications were kept in secure cabinets inaccessible to clients. LPAs Farlow, Brown, and Mann did not observe night lights in the hallways towards the clients bathrooms. Deficiency will be issued. The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility.
*** Continuation in LIC809C ***
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Lavette FarlowTELEPHONE: 951-248-0304
LICENSING EVALUATOR SIGNATURE:
DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2024
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 5


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: RODRIGUEZ FAMILY HOME
FACILITY NUMBER: 331881099
VISIT DATE: 08/21/2024
NARRATIVE
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Moreover, LPAs Farlow, Brown, and Mann observed that Licensee/Adminstrator Munoz made alteration at the facility as evidenced of Formal dining converted to a clients room. Deficiency will be issued.

Yards/Outside: One shaded patio, two (2) side gate with self-latching handle on the left and right side of the house that leads into the backyard, attached two (2) car garage observed. All outdoor pathways were free of obstructions.

Food Service: LPAs Farlow, Brown, and Mann observed two (2) day(s) supply of perishable food and seven (7) day(s) supply of non-perishables food and snacks. Dishes, cups, and utensils were stored properly.


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

Record Review: LPAs Farlow, Brown, and Mann reviewed two (2) client files for admission agreements, medical assessments/physician reports, and Individual Program Plan (IPP). LPAs Farlow, Brown, and Mann observed files reviewed were complete. LPAs Farlow, Brown, and Mann also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test result. LPAs Farlow, Brown, and Mann observed that files reviewed were complete.

LPAs Farlow, Brown, and Mann reviewed two (2) clients’ medications and LPAs observed that one (1) of Client#2 (C2) medication was not given per C2 doctors order. Deficiency will be issued.

Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809D, and Appeal Rights were discussed, and copies were provided to Licensee/Administrator Ivette Munoz.

SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Lavette FarlowTELEPHONE: 951-248-0304
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 08/21/2024 03:30 PM - It Cannot Be Edited

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: RODRIGUEZ FAMILY HOME
FACILITY NUMBER: 331881099

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(5)(B)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (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 designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions.

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 by not ensuring that Client #2 (C2) one (1) medication is given according to C2 doctors' order which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/22/2024
Plan of Correction
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Licensee stated to train all staff on CCR 80075(b)(5)(B) and submit proof of staff training log to LPA Farlow on 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: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Lavette FarlowTELEPHONE: 951-248-0304
LICENSING EVALUATOR SIGNATURE:
DATE: 08/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 08/21/2024 03:30 PM - It Cannot Be Edited

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: RODRIGUEZ FAMILY HOME
FACILITY NUMBER: 331881099

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(e)(2)
Fixtures, Furniture, Equipment, and Supplies
(e) Emergency lighting, which shall include at a minimum working flashlights or other battery-powered lighting, shall be maintained and readily available in areas accessible to clients and staff. (2) Night lights shall be maintained in hallways and passages to nonprivate bathrooms.

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 by not ensuring that night lights are maintained in hallways and passages to nonprivate bathrooms, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2024
Plan of Correction
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Licensee stated to obtain/purchase night lights and submit proof to LPA Farlow on 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: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Lavette FarlowTELEPHONE: 951-248-0304
LICENSING EVALUATOR SIGNATURE:
DATE: 08/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 08/21/2024 03:30 PM - It Cannot Be Edited

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: RODRIGUEZ FAMILY HOME
FACILITY NUMBER: 331881099

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80086(c)

80086 Alterations to Existing Building or New Facilities (c) Prior to construction or alterations, state or local law requires that all facilities secure a building permit,
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 building permit was obtained prior to alteration at the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2024
Plan of Correction
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Licensee stated to obtain a permit for the alteration completed at the facility and submit to LPA Farlow on 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: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Lavette FarlowTELEPHONE: 951-248-0304
LICENSING EVALUATOR SIGNATURE:
DATE: 08/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5