331881331-8-22-2023-18-AS-JSRS-CUXVGP-20230822162553

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881331
Report Date: 08/22/2023
Date Signed: 08/22/2023 04:25:59 PM

Document Has Been Signed on 08/22/2023 04:25 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	ERICA B INDEPENDENT LIVING FACILITY		FACILITY NUMBER:	331881331
ADMINISTRATOR:	JOHNSON, LA SUNEA		FACILITY TYPE:	735
ADDRESS:	3656 GINGER ST		TELEPHONE:	(818) 818-1817
CITY:	PERRIS	STATE: CA	ZIP CODE:	92571
CAPACITY: 6		CENSUS: 5	DATE:	08/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:35 PM
MET WITH:	Erica Graham-Bullock, Licensee		TIME COMPLETED:	04:30 PM

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) Jacqueline Shaw Ross arrived at the facility to conduct a required annual visit. LPA was greeted at the door by Licensee, Erica Graham-Bullock and the purpose of the visit was explained. The facility is approved for six (6) ambulatory individuals ages 18-59. Client groups served are developmentally disabled adults. The facility is a two (2) story four (4) bedroom three (3) bathroom home. At the time of visit there was one(1) client home, one(1) client at a home visit, one (1) client at a doctor's appointment and three (3) clients at day program. One other staff was present in addition to the Licensee. LPA conducted one (1) staff and one (1) client interview. A tour of the facility was conducted inside and out. There are two (2) clients to a bedroom. LPA observed the bedroom furniture to be in good condition. The kitchen was well-stocked, sharps and hazardous chemicals are kept locked away. Client bedrooms were clean and were observed to have the required furniture, bed linens, proper lighting, drawer/closet space to accommodate each resident. Client restrooms were checked and observed to be clean; toilets and water faucets worked properly, shower was free of mold/mildew, Non-skid mats were in place, hand washing signage was posted. LPA measured the water temperature in the restrooms and found the water, in the hall restroom, to be within regulatory limits, measuring at 118.2 degrees Fahrenheit. Client bath towels and toiletries were adequately stocked. Common areas were clean and all doorways were clear of obstructions inside the home. The kitchen was checked and observed to be within Title 22 regulations. There was an adequate supply of food for residents in care; a minimum of one week supply of non-perishable and a two day supply of perishable food. CONTINUED ON LIC809C...

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ERICA B INDEPENDENT LIVING FACILITY	FACILITY NUMBER: 331881331
	VISIT DATE: 08/22/2023

NARRATIVE

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Smoke and carbon monoxide detectors were checked, and were in good working order. Three (3) fire extinguisher were fully charged. The backyard was observed to be fully fenced with an unlocked gate and plenty of shade via two umbrella's over picnic tables.

Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility as well as the Licensee's administrator's certificate.

All resident medication is kept locked in medication cabinet in the dining room and LPA reviewed medications and found all medication listed on MARS and all required labeling was found to be in place. No medication errors observed at this time.

LPA reviewed staff files. Staff are appropriately attached to the facility. Background clearance and cpr/first aid certification are in each file.

LPA reviewed client files. Files contain current, up to date documentation that includes appraisal reports, admissions agreements, and physicians reports of all clients.

LPA reviewed the facility's emergency and disaster plan. LPA inquired about emergency drills and if a log or documentation drills were kept on file. Licensee stated drills are conducted monthly but does not keep documentation on file such as dates drill were done, how often, names of participants and what type of drill was conducted. LPA explained to Licensee the importance of keeping a log of emergency drills on file.

There is one (1) deficiency that is 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 where a copy of this report, LIC809D/LIC811 and a copy of Appeal Rights was provided to Licensee Erica Graham-Bullock.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 08/22/2023 04:25 PM - It Cannot Be Edited

Created By: Jacqueline Shaw Ross On 08/22/2023 at 03:50 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: ERICA B INDEPENDENT LIVING FACILITY	FACILITY NUMBER: 331881331
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1565(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/05/2023
	Plan of Correction
1 2 3 4	Licensee will create and submit a log of emergency drills that will include the dates of each drill, how often drills are conducted, what type of drill was conducted, names of all who participated in each drill. Licensee will submit a copy of drill log to the department by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Jacqueline Shaw Ross

LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

LIC809 (FAS) - (06/04)

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