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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881331
Report Date: 10/29/2024
Date Signed: 10/29/2024 06:35:23 PM

Document Has Been Signed on 10/29/2024 06:35 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: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:
10/29/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
05:45 PM
MET WITH:Erica Bullock-Graham - Licensee TIME VISIT/
INSPECTION COMPLETED:
06:45 PM
NARRATIVE
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Licensing Program Analyst (LPAs) Sara Martinez and Janette Romero conducted an unannounced case management visit to address the following the deficiencies observed on 10/29/2024 visit.

LPAs observed the kitchen refrigerator to be locked with what appeared to be a stainless-steel chain and laminated steel shackle keyed padlock around the door handles. LPAs observed a chain and lock around the handles of the kitchen cabinets. Staff present reported they did not have master lock key on the premises to unlock the refrigerator. LPAs also observed the pantry to be locked with a smaller chain and master lock. When LPAs returned to the facility the lock on the two pantry cabinets and the refrigerator.

Additionally, during a record review of Client 2’s admission agreement signed and dated 8/28/2024, subsection 5(A)3 indicates clients will receive an eviction notice if they do not attend day program Monday-Friday. This poses a potential personal rights to clients in care. A deficiency will be issued under Title 22 Regulation 80072(a)(3) along with a plan of correction.

Licensee reported Client 1 (C1) eloped from the facility on 10/2/2024, 10/7/2024, and 10/14/2024 and the facility did not report C1’s absence to Community Care Licensing. During today’s visit, Staff 1 handed LPA a written incident report reporting C1’s absences on the dates noted above, which does not meet the reporting requirements of providing the licensing agency with a written report within seven (7) following the incident. This poses a potential health, safety, or personal rights risk to clients in care. A deficiency will be issued under Title 22 Regulation 80061(b)(1)(E) along with a plan of correction.

An exit interview was conducted, and a copy of this report, LIC 809-D, appeal rights, LIC 811 was provided to Eva Bruce.

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2024
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 10/29/2024 06:35 PM - It Cannot Be Edited


Created By: Sara Martinez On 10/29/2024 at 04:37 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: 10/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/15/2024
Section Cited
CCR
80072(a)(3)

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80072 Personal Rights (a) ...each client shall have personal rights which include... (3) To be free from corporal or unusual punishment, infliction of pain... interference with the daily living functions, including eating.... physical functioning. This requirement was not being met as evidenced by:
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Licensee removed the locks from the refrigerator and kitchen cabinets when LPAs returned to the facility. Licensee will conduct staff training for this personal rights regulation cited and submit proof of training to LPA by the plan of correction date.
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Based on observation, interviews, and records review, the Licensee locked the refrigerator with a lock and had put in the client's admission's agreement they were subjected to eviction if they did not attend day program Monday-Friday. This poses a potential health/safety/personal rights risk to clients in care.
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Type B
11/15/2024
Section Cited
CCR80061(b)(1)(E)

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80061 Reporting Requirements
(b) ...during the operation of the facility... a report shall be made to the licensing agency...(1) Events reported shall include the following(E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client. Requirement was not being met as evidenced by:
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Licensee will conduct staff training on the reporting requirements and provide proof of training and training material to LPA by the plan of correction date.
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Licensee did not report SIRs to the Department for C1 regarding AWOL on 10/02, 10/07, and 10/14
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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:Sara Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2024


LIC809 (FAS) - (06/04)
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