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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881190
Report Date: 05/23/2024
Date Signed: 05/23/2024 12:27:45 PM

Document Has Been Signed on 05/23/2024 12:27 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SPOELSTRA LLC DBA VOICE BANNINGFACILITY NUMBER:
331881190
ADMINISTRATOR/
DIRECTOR:		CROKE, KATHYFACILITY TYPE:
775
ADDRESS:2985 W LINCOLN STTELEPHONE:
(909) 792-2428
CITY:BANNINGSTATE: CAZIP CODE:
92226
CAPACITY: 60CENSUS: 31DATE:
05/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Kathy Croke - Program DirectorTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Kathy Croke, Program Director, and discussed the purpose of the visit.
The facility is an Adult Day Program with a license capacity of 60 and a current census of 31 clients. During today's visit, there were 17 direct care staff present. LPA conducted an overall inspection, which included, but was not limited to the following:
The facility's passageways were clear and free of obstructions. The facility has two (2) main areas designated for client activities and a private client lounge. The facility has sufficient supply of arts supplies, board games, sensory activity items for client use. Client restrooms and changing areas were odor free and operating in sanitary conditions. The facility has a sufficient supply of personal hygiene products for client in care. Cleaning solutions stored in the kitchen were kept locked and stored away from food items. The facility has operating fire/carbon monoxide alarms and telephone service. The facility has posted in a common area: facility license, facility evacuation sketch, Community Care Licensing complaint poster, infection control prevention signs, and a emergency disaster plan with emergency telephone numbers. Client medications are centrally stored and kept in a locked container. The facility has an infection control and disaster plan on file. Five (5) staff files were observed to be complete, and included criminal record clearances and/or exemptions. Five (5) client files were reviewed. LPA observed Client #1 (C1) did not have an admissions agreement on file and a deficiency was cited.

Based on observations and record review, a deficiency is being cited per Title 22 of the California Code of Regulations. An exit interview was conducted were the licensing reports and correction plans were discussed with the Program Director. A copy of the reports were provided with Appeal Rights to the Program Director at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2024
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 05/23/2024 12:27 PM - It Cannot Be Edited


Created By: Magda Malcore On 05/23/2024 at 11:51 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: SPOELSTRA LLC DBA VOICE BANNING
FACILITY NUMBER: 331881190

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82068(a)
Admission Agreements
(a) The licensee shall complete and maintain an individual written admission agreement with each client and the client's authorized representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by Client #1 (C1) did not have an Admissions Agreement on file for review; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/07/2024
Plan of Correction
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The Licensee shall submit to the Licensing Agency a copy of C1's admissions agreement by POC due date
Section Cited
Client Medical Assessments
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:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2024


LIC809 (FAS) - (06/04)
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