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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881331
Report Date: 05/08/2023
Date Signed: 05/08/2023 04:32:40 PM

Document Has Been Signed on 05/08/2023 04:32 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:ERICA B INDEPENDENT LIVING FACILITYFACILITY NUMBER:
331881331
ADMINISTRATOR:JOHNSON, LA SUNEAFACILITY TYPE:
735
ADDRESS:3656 GINGER STTELEPHONE:
(818) 818-1817
CITY:PERRISSTATE: CAZIP CODE:
92571
CAPACITY: 6CENSUS: 6DATE:
05/08/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:18 PM
MET WITH:Erica Graham Bullock, LicenseeTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Yolanda Delgado conducted a case management visit on the health, safety and welfare of the clients in care as LPA was outside parked in state vehicle in front of the facility's front door awaiting for Licensee to arrive and LPA observed a male being dropped off in front of the home and male walked up to the front door and rang the Ring bell and knocked on the door; no answer at the door. LPA made contact with male and introduce herself and learned that the male was a client of the home.

(LPA) Delgado met with Erica Bullock. LPA was informed that six (6) residents currently reside at this facility, five (5) is at Day Program. The Administrator on duty during the time of the visit. Five (5) clients arrived during the visit.

LPA toured the facility and observed all facility utilities to be on and operating without issue, food supply is sufficient, there is no immediate concern for residents in care . LPA reviewed client (C1) LIC 602.

There are two (2) deficiencies that are being cited and there are no civil penalties per California Health & Safety Code and Code of Regulations, Title 22, Division 6. An exit interview was conducted with Erica Bullock and a copy of this report, 809D and Appeal Rights will be emailed and a receipt of confirmation will be requested.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE: DATE: 05/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/08/2023
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 05/08/2023 04:32 PM - It Cannot Be Edited


Created By: Yolanda Delgado On 05/08/2023 at 03:35 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: ERICA B INDEPENDENT LIVING FACILITY
FACILITY NUMBER: 331881331

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/09/2023
Section Cited
CCR
80061(b)(D)

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Reporting Requirements: (b) Upon the occurrence, during the operation of the facility, of any of the events specified in...In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurence of such
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Licensee will review regulation and report within the time frame stated and send a self-certifying email that compliance in rules and regulations to LPA Delgado by POC due date.
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event. (D) Any injury to any client which requires medical treatment.
Based on observation and interviews, the Licensee did not comply with the above regulation in C1 seeked medical attention; This is an immediate safety risk to all residents in care.
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Type B
05/09/2023
Section Cited
CCR80072(a)(2)

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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:
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/
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Licensee will remove latches and locks and send a photograph by email to LPA Delgado by POC due date.
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her needs. Based on observation and interviews, the Licensee did not comply with the above regulation in two grey foldable wood panels in kitchen areas observed with atches and master locks inaccessible to clients; This is an immediate safety risk to all residents 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: 05/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2023


LIC809 (FAS) - (06/04)
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