<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881331
Report Date: 06/20/2024
Date Signed: 06/20/2024 11:08:52 AM

Document Has Been Signed on 06/20/2024 11:08 AM - 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:ERICA B INDEPENDENT LIVING FACILITYFACILITY NUMBER:
331881331
ADMINISTRATOR/
DIRECTOR:		JOHNSON, LA SUNEAFACILITY TYPE:
735
ADDRESS:3656 GINGER STTELEPHONE:
(818) 818-1817
CITY:PERRISSTATE: CAZIP CODE:
92571
CAPACITY: 6CENSUS: 6DATE:
06/20/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Licensee, Erica Graham-BullockTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit to the facility in order to conduct a case management. The purpose of thee visit was to cite observed deficiencies and deliver an amended report complaint control #18-AS-20240513124312. LPA met with Licensee, Erica Graham-Bullock, who was informed of the purpose of the visit.

LPA attempted to review records for Client #1 (C1). LPA was informed by licensee that C1 did not have medical history records, pre admission appraisal, or admission agreement for C1 and did not have a file for them. Therefore, the facility failed to keep records for C1.

During inspection conducted on June 12. 2024, LPA conducted a walk through of the home and observed (4) cameras in facility common areas. LPA reviewed the facilities admission agreements and program plan. LPA found no addendum or specification for the usage of video cameras. Therefore, the facility failed to inform the department and submit documentation as detail in Reference material 2-58000 for video surveillance.

Deficiencies were cited in accordance with California Code of Regulations Title 22 Division 6 Chapter 1. Plans of correction were created with the licensee and documented.

An exit interview was conducted where this report was reviewed and provided to Licensee, Erica Graham-Bullock.

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 06/20/2024 11:08 AM - It Cannot Be Edited


Created By: Janira Arreola On 06/20/2024 at 10:29 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: ERICA B INDEPENDENT LIVING FACILITY
FACILITY NUMBER: 331881331

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/27/2024
Section Cited
CCR
80070(a)

1
2
3
4
5
6
7
80070 (a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
The licensee agreed to have all required paper prior to accepting a new client. The licensee agreed to send the LPA a self certified statment of their preadmission process by the POC due date.
8
9
10
11
12
13
14
Based on interviews it was found that C1 did not have a record maintained with admission agreement, preappraisal, or medical records. This poses a potential personal right, health or safety risk to residents in care.
8
9
10
11
12
13
14
Type B
06/27/2024
Section Cited
CCR80022(j)

1
2
3
4
5
6
7
80022 (j) Any changes in the plan of operation which affect the services to clients shall be subject to licensing agency approval and shall be reported as specified in Section 80061. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
The licensee agreed to send program plan addendum, in addition to signed consent forms for current clients in care, and physical plant map of where the caemras are being kept. This due by POC date.
8
9
10
11
12
13
14
Based on interview and records review the facility made changes to their house rules and added video surveillance without notification or approval of the department. This poses a potential health safety or personal rights risk to residents in care.
8
9
10
11
12
13
14
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: 06/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2