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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881317
Report Date: 06/12/2023
Date Signed: 06/12/2023 02:31:06 PM

Document Has Been Signed on 06/12/2023 02:31 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:MISSION BELL ADULT RESIDENTIAL CARE HOMEFACILITY NUMBER:
331881317
ADMINISTRATOR:BOYER, MARITESFACILITY TYPE:
735
ADDRESS:435 IDYLLWILD DRIVETELEPHONE:
(951) 654-0774
CITY:SAN JACINTOSTATE: CAZIP CODE:
92583
CAPACITY: 15CENSUS: 13DATE:
06/12/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:08 PM
MET WITH:Marites Boyer, AdministratorTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to the facility to conduct a case management visit on the health, safety, and welfare of residents in care. LPA met with Marites Boyer. LPA was informed that thirteen (13) residents currently reside at this facility; nine (9) are at Day Program. There were two (2) staff on duty during the time of the visit, Administrator arrived at the end of the visit.

LPA toured the facility and observed all facility utilities to be on and operating without issue, food supply is sufficient, no issues with medications; there is no immediate concern for residents in care.

Two (2) deficiencies are being cited and no civil penalties per California Health & Safety Code and Code of Regulations, Title 22, Division 6. An exit interview was conducted with Marites Boyer and a copy of this report will be provided..
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE: DATE: 06/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2023
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 06/12/2023 02:31 PM - It Cannot Be Edited


Created By: Yolanda Delgado On 06/12/2023 at 01:36 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: MISSION BELL ADULT RESIDENTIAL CARE HOME
FACILITY NUMBER: 331881317

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/16/2023
Section Cited
CCR
80087(a)(1)

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BUILDINGS AND GROUNDS:
a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (1) The licensee shall take measures to keep the facility free of flies and other insects.
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Licensee will obtain a exterminator for the room and will email a copy of the invoice to LPA Delgado by POC due date.
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This requirement is not met as evidenced by:Based on observation and interview the licensee did not comply with the section cited above in client room #3 has bed bugs. This poses an immediate health, safety or personal rights risk to persons in care.
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Type B
06/16/2023
Section Cited
CCR80072(a)(1)

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PERSONAL RIGHTS: (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons.This requirement is not met as
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Licensee will be having a CPI training with all staff at the facility on 6/14/2023. S3 has been placed on Administrative leave until internal investigation is completed and a determination is made. Licensee will email LPA with the determination.
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evidenced by: Interviews revealed that S3 grabbed R1 by the hair. The licensee did not comply with the section cited above. This poses an immediate health, safety or personal rights risk to persons 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:Jazmond D Harris
LICENSING EVALUATOR NAME:Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2023


LIC809 (FAS) - (06/04)
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