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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530021
Report Date: 11/18/2024
Date Signed: 11/18/2024 11:43:12 AM

Document Has Been Signed on 11/18/2024 11:43 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:SYCAMORE HOUSEFACILITY NUMBER:
335530021
ADMINISTRATOR/
DIRECTOR:		TATE, LANEEFACILITY TYPE:
735
ADDRESS:29104 SYCAMORETELEPHONE:
(909) 969-0068
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92530
CAPACITY: 3CENSUS: 1DATE:
11/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Licensee/Administrator Lanee TateTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
NARRATIVE
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On 11/18/2024 at 08:45 AM, Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility to conduct the required comprehensive annual inspection. LPA Brown was greeted by Licensee/Administrator Lanee Tate and gained access at the home and LPA Brown explained the purpose of the visit to Licensee/Administrator Tate.

The facility is a three (3) bedroom, two (2) bathroom home with a kitchen/dining area, living room, laundry room, an attached garage and backyard. The facility is vendorized by Inland Regional Center (IRC). LPA Brown completed a walkthrough of the facility, review of records, and medications audit.



Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD), LPA Brown observed no client during the visit. Licensee/Administrator Tate informed LPA Brown that their one (1) client’s out in the community. There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 74 degrees Fahrenheit. LPA Brown inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs, and sufficient lighting. LPA Brown inspected client bathroom; bathroom was clean, and appliances were found functional. Water temperature tested at 108.6 degrees Fahrenheit. The facility is equipped with operational combined smoke detectors and carbon monoxide detectors, charged fire extinguisher, and first aid kit with first aid book.

Posters such as; the personal rights, CCLD complaint poster, and emergency disaster plan were posted in a common area. Client medications were kept in secure cabinets inaccessible to clients. LPA Brown observed no night lights at the hallway leading to clients' shared bathrooms. Deficiency will be issued. The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility.
*** Continuation in LIC809C ***
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2024
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 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: SYCAMORE HOUSE
FACILITY NUMBER: 335530021
VISIT DATE: 11/18/2024
NARRATIVE
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During the tour of the facility, LPA Brown observed one (1) sharp scissor on top of the kitchen counter, not locked and accessible to client in care. Deficiency will be issued. LPA Brown observed one (1) window screen in disrepair. Technical Violation will be issued. However, LPA Brown observed there are food supplies stored in the same closet where soaps, and cleaning compounds were stored. Deficiency will be issued.

Yards/Outside: One shaded patio, one (1) side gate with self-latching handle on the left side of the house that leads into the backyard, attached two (2) car garage observed. All outdoor pathways were free of obstructions.

Food Service: LPA observed more than two (2) days supply of perishable food and more than seven (7) days supply of non-perishable food and snacks. Dishes, cups, and utensils were stored properly.


Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPA Brown observed Infection Control Plan, updated Surety Bond and Liability Insurance maintained at the the facility. LPA Brown observed no Register of Facility Clients (LIC9020) maintained at the facility. Technical Violation will be issued. LPA Brown reviewed one (1) client file for admission agreements, medical assessments/physician reports, Individual Program Plan (IPP), and centrally stored medication list. LPA Brown observed that Client #1 (C1) does not have the required Medical Assessment/physician report and per documents review, LPA Brown noted that C1 was admitted at the facility on 03/19/2024 without the required medical assessment/physician report. Deficiency will be issued. In addition, LPA Brown observed that Client #1 (C1) does not have the required record of centrally stored prescription medications in C1 file. Deficiency will be issued. LPA Brown also reviewed staff and administrator's file for First Aid/CPR certification, CPI Certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test result. LPA Brown observed no issues, files reviewed were complete. LPA Brown audited one (1) client medications and no issues were observed. Licensee/Administrator Tate informed LPA Brown that C1 does not have Personal & Incidental (P&I) yet.

Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809D, LIC9102 and Appeal Rights were discussed, and copies were provided to Licensee/Administrator Lanee Tate.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 11/18/2024 11:43 AM - It Cannot Be Edited


Created By: Melody Brown On 11/18/2024 at 10:34 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
, CA 92507

FACILITY NAME: SYCAMORE HOUSE
FACILITY NUMBER: 335530021

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that the one (1) sharp scissor observed on top of the kitchen counter was locked and not accessible to client in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/19/2024
Plan of Correction
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Licensee immediately locked the one (1) sharp scissor observed on top of the kitchen counter during the visit. Licensee stated to train all staff on CCR 80087(g) and submit proof of staff training log to LPA Brown on Plan of Correction (POC) due date.
Type A
Section Cited
CCR
80069(b)
Client Medical Assessments
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not obtaining Client #1 (C1) Medical Assessment prior to accepting C1 into care at the facility on 03/19/2024 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/19/2024
Plan of Correction
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Licensee stated to train all staff on CCR 80069(b) and submit proof of staff training log to LPA Brown on POC due date. Also, Licensee stated to submit a medical appointment date for C1 to complete the required medical assessment to LPA Brown on POC due date.
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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2024


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 11/18/2024 11:43 AM - It Cannot Be Edited


Created By: Melody Brown On 11/18/2024 at 10:34 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
, CA 92507

FACILITY NAME: SYCAMORE HOUSE
FACILITY NUMBER: 335530021

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(e)(2)
Fixtures, Furniture, Equipment, and Supplies
(e) Emergency lighting, which shall include at a minimum working flashlights or other battery-powered lighting, shall be maintained and readily available in areas accessible to clients and staff. (2) Night lights shall be maintained in hallways and passages to nonprivate bathrooms.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that night lights are maintained in hallways and passages to nonprivate bathrooms which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/25/2024
Plan of Correction
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Licensee stated to obtain/purchase night lights and submit proof of installed night lights at the facility to LPA Brwown on Plan of Correction (POC) due date.
Type B
Section Cited
CCR
80076(a)(16)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (16) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that the cleaning compounds or solutions were stored separate from food supplies which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/25/2024
Plan of Correction
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Licensee stated to remove the food supplies in the closet where cleaning supplies/compounds.solutions were stored and submit proof to LPA Brown on POC due date.
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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2024


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 11/18/2024 11:43 AM - It Cannot Be Edited


Created By: Melody Brown On 11/18/2024 at 10:34 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
, CA 92507

FACILITY NAME: SYCAMORE HOUSE
FACILITY NUMBER: 335530021

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(k)(7)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Client #1 (C1) has a record of centrally stored prescription medications in C1 file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/25/2024
Plan of Correction
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Licensee stated to submit a copy of C1 record of centrally stored prescription medications to LPA Brown on Plan of Correction (POC) due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2024


LIC809 (FAS) - (06/04)
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