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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881201
Report Date: 11/06/2024
Date Signed: 11/06/2024 01:58:28 PM

Document Has Been Signed on 11/06/2024 01:58 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:CONCEPT FOR LIFE HOME LLCFACILITY NUMBER:
331881201
ADMINISTRATOR/
DIRECTOR:		DUPREE, TIFFANYFACILITY TYPE:
735
ADDRESS:25791 FIR AVETELEPHONE:
(323) 921-8391
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY: 4CENSUS: 3DATE:
11/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:House Manager, Dulce CarilloTIME VISIT/
INSPECTION COMPLETED:
02:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit. LPA was granted entry and met with House Manager, Dulce Carrillo who was informed of the purpose of the visit, Administrator and Licensee Tiffany Dupree was available over the phone during the visit. At the time of the visit there was (1) staff and (2) clients present, (1) client was out the community. LPA conducted a walk through, records review, and interviews during the visit.

The facility is a two story home with (4) bedrooms and (2) bathrooms for clients, (1) bedroom and (1) bathroom is for staff downstairs. No firearms or ammunition are being kept at the facility. The facility is an adult residential facility serving clients ages 18 to 59.

Infection Control: The LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility.



Physical Plant: Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards, and the facility pool was observed fenced and locked during the visit. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to clients. The smoke detector and carbon monoxide was operational, and the hot water temperature 116.7F.

Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2024
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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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: CONCEPT FOR LIFE HOME LLC
FACILITY NUMBER: 331881201
VISIT DATE: 11/06/2024
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Care & Supervision/Administration: Adequate staff are present for the supervision of clients during the visit. LPA also reviewed the staff schedule showing adequate staff coverage. Required postings were found in the facility.

Record Review and Resident/Staff Files: LPA reviewed (2) staff files and training. All staff have criminal clearance and updated training along with CPR/First Aid Certification. Two (2) client files were reviewed, which revealed (1) of (3) clients did not have a signed consent form for video surveillance in the home. Deficiency was cited and plan of correction was created with licensee.

Health Related Services/ Incidental Medical Services: All client medication was locked in a file cabinet. LPA reviewed client medications for (2) client and found all medication listed on MARS and accounted for.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing the facility's last fire drill 10/23/2024, which met the department requirements. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies.

An exit interview was conducted where this report, LIC809-D page and appeal rights were reviewed and provided.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/06/2024 01:58 PM - It Cannot Be Edited


Created By: Janira Arreola On 11/06/2024 at 01:23 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: CONCEPT FOR LIFE HOME LLC
FACILITY NUMBER: 331881201

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80072(a)(2)
80072 Personal Rights (a)…each client shall have personal rights which include…: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, (1) of (3) clients did not have a signed consent form in their file for the use of video surveillance in the facility. This poses a potential health, safety or personal rights risk to clients in care.
POC Due Date: 11/08/2024
Plan of Correction
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The licensee agreed to have the responsible party of the client sign the consent form and send proof of this to the LPA by the 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:Tricia Danielson
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2024


LIC809 (FAS) - (06/04)
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