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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336403110
Report Date: 09/16/2022
Date Signed: 09/16/2022 12:18:02 PM

Document Has Been Signed on 09/16/2022 12:18 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SLB INCORPORATED-LYDIA'S HOMEFACILITY NUMBER:
336403110
ADMINISTRATOR:ELLEN AMANTEFACILITY TYPE:
735
ADDRESS:12871 VELVET LEAF ST.TELEPHONE:
(951) 243-7507
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY: 6CENSUS: 5DATE:
09/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:52 AM
MET WITH:Caregiver Lolita GalangTIME COMPLETED:
12:25 PM
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Licensing Program Analyst (LPA) Jesse Gardner made an unannounced visit to the facility to conduct an annual inspection with an emphasis on infection control. LPA met with Caregivers Lolita Galang, and Mikko Galang (S1) and explained the purpose of the visit. Present in the home during time of visit was three (3) staff as well as five (5) residents. Administrator Ellen Amante arrived while conducting the tour. There are currently no cases of COVID-19 within the facility.

During today's visit, LPA toured the facility and made observations pertaining to the facility's infection control measures. LPA observed proper signage throughout the facility, sufficient hand hygiene supplies, and sufficient cleaning and disinfecting provisions. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the proper use and disposal of PPE and overall infection control. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and residents for COVID-19, when and how to isolate/quarantine residents, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas. The facility also has a plan in place to monitor residents regularly for any changes in condition and to subsequently notify the resident's physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illness.

During the visit, LPA noted the room of Resident 1 (R1) to have a torn mattress cover in several places, and a locked closet containing R1's clothing. S1 stated that the locked closet was to prevent R1 from throwing their clothes around the room. Thus, 2 deficiencies were cited per Title 22, Division 6, of the California Code or Regulations. An exit interview was conducted and a copy of this report was provided along with copies of the LIC811, LIC809-D, and Appeal Rights.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2022
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 09/16/2022 12:18 PM - It Cannot Be Edited


Created By: Jesse Gardner On 09/16/2022 at 11:38 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: SLB INCORPORATED-LYDIA'S HOME
FACILITY NUMBER: 336403110

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(c)(1)
85088 (c)(1) Fixtures, Furniture, Equipment and Supplies. (c) The licensee shall ensure provision to each client..(1) An individual bed..in good repair..This requirement was not being met as evidenced by:
Deficient Practice Statement
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Based on observation R1’s mattresses cover needs replacing. Licensee did not adhere to the regulation. This presents a potential health and safety and personal rights risk to clients in care.
POC Due Date: 09/30/2022
Plan of Correction
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Licensee states that the mattress cover will be replaced and will submit receipt to LPA by POC date. Licensee also states that in-service training will be conducted to inspect for mattress deficiencies, as well as a review of the regulation and submit to LPA by POC date.
Type B
Section Cited
CCR
80072(a)(3)
80072(a)(3) Personal Rights. (a) Except for..each client shall have personal rights which include, but are not limited to, the following: (3) To be free from .. mental abuse..or withholding of..clothing...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, and interview, R1’s closet containing their clothes is kept behind a locked door. Licensee did not adhere to the regulation. This presents a potential health and safety and personal rights risk to clients in care.
POC Due Date: 09/30/2022
Plan of Correction
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Licensee states that the closet will not be locked, and that a care plan will be developed to manage R1’s behaviors. Further, In-service training will be conducted with staff on the developed care plan, and proof of such will be submitted to LPA by POC date along with the Care Plan.
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:Deborah Mullen
LICENSING EVALUATOR NAME:Jesse Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2022


LIC809 (FAS) - (06/04)
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