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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336407591
Report Date: 11/21/2022
Date Signed: 11/21/2022 03:12:26 PM

Document Has Been Signed on 11/21/2022 03:12 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
PACIFIC INLAND CR, 3737 MAIN ST., SUITE 600
RIVERSIDE, CA 92501
FACILITY NAME:PLAN IT LIFEFACILITY NUMBER:
336407591
ADMINISTRATOR:DANA TAYLORFACILITY TYPE:
733
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 6CENSUS: 6DATE:
11/21/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Dana Taylor Administrator, Chiante Leonard Facility ManagerTIME COMPLETED:
03:20 PM
NARRATIVE
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On November 21, 2022 at 9:00 AM, Licensing Program Analysts (LPA) Jessica Peete conducted an unannounced annual inspection at Plan It Life Short Term Residential Therapeutic Program (STRTP). LPA was met at by Shift Manager Natalie Gonzalez. LPA Peete visited the facility on 11/10/2022 to complete inspection of the Physical Plant, Operational Requirements, Disaster Preparedness, Core Therapeutic Services and Emergency Intervention Plan.

At 9:10 AM LPA conducted three client interviews (C1-C3)

At 9:55 AM LPA began review of five staff files (S1-S5) assisted by facility manager Chiante Leonard. The facility manager explained all staff training records are kept at the corporate office. In the interim LPA completed two staff interviews (S2 and S4). Administrator Dana Taylor arrived at the facility at 12:50 PM to provide staff training files and assist with this area of the inspection.

At 2:19 PM LPA observed licensee did it comply with California Code of Regulations (CCR) 80066(a)(11). The regulation is stated as follows: (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents… The licensee did not have the tuberculosis test results for S5.

Deficiencies are being cited based on LPA observation; see LIC809 D. An exit interview was conducted and a copy of this report and appeal rights were given to Facility Manager Chiante Leonard.

SUPERVISORS NAME: Cheraki Davis
LICENSING EVALUATOR NAME: Jessica M Peete
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2022
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 11/21/2022 03:12 PM - It Cannot Be Edited


Created By: Jessica M Peete On 11/21/2022 at 02:23 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
, 3737 MAIN ST., SUITE 600
RIVERSIDE, CA 92501

FACILITY NAME: PLAN IT LIFE
FACILITY NUMBER: 336407591

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above which poses a potential health, safety, or personal rights risk to persons in care. The licensee did not have the tuberculosis test results for one of five staff members. The tuberculosis test documents were not on file for S5.
POC Due Date: 12/12/2022
Plan of Correction
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The licensee will have S5 complete and provide proof of the tuberculosis test results.
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:Cheraki Davis
LICENSING EVALUATOR NAME:Jessica M Peete
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2022


LIC809 (FAS) - (06/04)
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