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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881257
Report Date: 11/20/2024
Date Signed: 11/20/2024 04:54:43 PM

Document Has Been Signed on 11/20/2024 04:54 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:OSLO HOMEFACILITY NUMBER:
331881257
ADMINISTRATOR/
DIRECTOR:		CLOYD, SHILOHFACILITY TYPE:
735
ADDRESS:3678 OSLO CTTELEPHONE:
(619) 292-9299
CITY:HEMETSTATE: CAZIP CODE:
92545
CAPACITY: 4CENSUS: 4DATE:
11/20/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:25 PM
MET WITH:Staff, Benny SmallTIME VISIT/
INSPECTION COMPLETED:
05:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannouned visit for an unrelated matter. This report is meant to document deficiencies found during the visit. LPA met with Staff, Benny Small who was informed of the purpose of the visit. There were (2) staff and (3) clients present during the visit. LPA conducted interviews, walk through and records review. The following was observed:

LPA conducted a review of regional office received incident reports and found no incidents have been reported to licensing for C1. LPA conducted a review of C1’s consumer notes which revealed incidents occurring on 11/12/2024, 11/13/2024, 11/14/2024, 11/15/2024, 11/16/2024, and 11/17/2024 were C1 engaged in making verbal threats to harm others, hitting object around them, and contacting law enforcement for C1. Therefore, the facility failed to reports to licensing.

LPA requested records for C1 including issued eviction notice, and LIC602 Medical Assesment for C1 which was missing in their record. These records were not produced to the LPA in a timely manner during the visit.

The facility is being cited for the above incidents. Plans of correction were created with staff, efforts to contact Administrator for exit interview were unsuccessful. An exit interview was conducted with Staff, Benny Small where this report along with appeal rights and LIC809-D page.

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2024
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 11/20/2024 04:54 PM - It Cannot Be Edited


Created By: Janira Arreola On 11/20/2024 at 04:29 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: OSLO HOME
FACILITY NUMBER: 331881257

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/06/2024
Section Cited
CCR
80069(b)(1)

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(b) In ARFs , prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.

(1) Such assessment shall be performed by a licensed physician, or designee, who is also a licensed professional, and the assessment shall not be more than one year old when obtained.
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POC is to get LIC602 and send to LPA by the POC due date. Written statement on procedure on obtaining the LIC602 before a client is admitted.
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Based on interviews and records review C1 did not have a LIC602 in their file.This poses a potential health safety or person rights risk.
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Type B
11/22/2024
Section Cited
CCR80070(d)

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(d) All client records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying.
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POC is to procude a written statement on how the facility plans to ensure records are avaible for licensing to inspect. This is due by the POC due date.
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Based on interviews and records review the facility did not produce the records of eviction notice and medical report for C1 during the visit. This poses a potential health saftey or personal rights risk to clients in care.
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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: 11/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 11/20/2024 04:54 PM - It Cannot Be Edited


Created By: Janira Arreola On 11/20/2024 at 04:50 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: OSLO HOME
FACILITY NUMBER: 331881257

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/06/2024
Section Cited
CCR
80061(b)

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80061 Reporting Requirements (b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event.
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POC is to send incident reports to licensing by the POC due date for C1.
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Based on records review and interview the facility failed to report incident for C1 to licensing. This poses a potential health saftey or person rights risk.
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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: 11/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2024


LIC809 (FAS) - (06/04)
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