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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881331
Report Date: 07/05/2024
Date Signed: 07/05/2024 11:20:36 AM

Document Has Been Signed on 07/05/2024 11:20 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:
07/05/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Licensee, Erica Graham-BullockTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced visit to the facility in order to conduct a plan of correction (POC) visit for deficiencies cited on 6/20/2024. The LPA met with Licensee, Erica Graham-Bullock, who was informed of the purpose of the visit. During today's visit LPA conducted a walk through, and conducted interviews and records review.

Deficiency was cited under Title 22 Regulation section 80072 Personal Rights. The POC made with the licensee was to meet with the residents and revise the house rules to account for personal rights by the POC due date of 6/21/2024. LPA received the POC from the licensee via email and the POC was reviewed. Revisions on the POC were emailed back on 7/3/2024 as the house rules submitted for the POC do not meet the department requirements for personal rights. LPA met with the licensee on today’s visit who submitted the corrections to LPA during the visit. The rules were signed by (5) of (6) residents, licensee stated they would send this signed form by the end of the business day to LPA.

The following deficiencies was not corrected by their POC due dates, but were corrected during today's POC visit. Civil penalties are being assessed for the dates the POC's was late:


Deficiency was cited under Title 22 Regulation section 80075 Health Related Services. The POC made with the licensee was to conduct a training with staff on proper medication documentation and send proof of this by the POC due date 6/27/2024. On today's visit LPA received written proof of training conducted with staff on medication documentation. Therefore, the POC was met and the deficiency was cleared and a clearance letter was issued to the licensee.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 07/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/05/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 FACILITY
FACILITY NUMBER: 331881331
VISIT DATE: 07/05/2024
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Deficiency was cited under Title 22 Regulation section 80070 Client Records. The POC made with the licensee was to have all required paperwork prior to accepting a new client including admission agreement, preappraisal, and medical assessment. The licensee agreed to send the LPA a self certified statement of their preadmission process to ensure these documents were kept in the client files by the POC due date of 6/27/2024. On today’s visit LPA received the self certified statement, therefore the POC was met and cleared. A clearance letter was provided to the Licensee.

The deficiencies were cleared at the time of the visit which are past the agreed upon POC due dates. Therefore, civil penalties will be issued from 6/28/2024 to 7/4/2024 in the amount of $100 per day, totaling $700 for each deficiency.

The following deficiencies were not corrected by the POC due date nor at the time of the visit. Civil Penalties are being assessed and will continue to accrue until correction has been submitted:


Deficiency was cited under Title 22 Regulation section 80022 Plan of Operation. The POC made with the licensee was to send program plan addendum, in addition to signed consent forms for current clients in care, and physical plant map of where the facility cameras are being kept. This due by POC date 6/27/2024. On today's visit LPA spoke with licensee who stated they would submit this to the LPA by the end of the business day.

The deficiency was not cleared at the time of the visit which is past the agreed upon POC due date. The licensee agreed to send this to LPA by the end of the business day. Therefore, civil penalties will be issued from 6/28/2024 to 7/4/2024 in the amount of $100 per day, totaling $800. The licensee was advised that civil penalties will continue to accrue $100 per day until the agreed upon POC is received.

An exit interview was conducted where this report, civil penalties pages, and clearance letters were reviewed and provided.

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 07/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2024
LIC809 (FAS) - (06/04)
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