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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336408330
Report Date: 06/12/2024
Date Signed: 06/12/2024 01:15:51 PM

Document Has Been Signed on 06/12/2024 01:15 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:CHUQUIMIA'S ADULT FAMILY HOME IIFACILITY NUMBER:
336408330
ADMINISTRATOR/
DIRECTOR:		LIDIA CHUQUIMIAFACILITY TYPE:
735
ADDRESS:7611 KELTY DRIVETELEPHONE:
(951) 776-9094
CITY:RIVERSIDESTATE: CAZIP CODE:
92508
CAPACITY: 4CENSUS: 3DATE:
06/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:20 AM
MET WITH:Lidia Chuquimia, LicenseeTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction and visit purpose. Upon arrival LPA learned that three (3) clients reside at this facility and there are currently one (1) caregiver present. There is an Infection Control Plan on file.

Client Records-Incident Reports/Clients Rights-Information/Dental- LPA began review of client records. Three (3) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment-three expired, and TB test results-no documentation, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables-one missing, and personal rights notification-one missing.

Personnel Records/Training/and Staffing- LPA began review of employee records- Two (2) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrator certification; expiration date 12/23/2024.



Food Service- Food prep areas are clean and organized. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a locked location for chemicals and sharps in the kitchen.

(Continued on LIC809C)
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE: DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2024
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 4
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
RIVERSIDE, CA 92507
FACILITY NAME: CHUQUIMIA'S ADULT FAMILY HOME II
FACILITY NUMBER: 336408330
VISIT DATE: 06/12/2024
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(Continuation from LIC809)

Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. LPA observed the facility to be clean and 6 exterior window screens need repair. The home is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured 126.7 degrees F. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. The LIC 610, emergency disaster plan is maintained. There are no firearms at this home. This home does have a pool and is locked at all times with fencing that is more than 5 ft. high around the perimeter of the pool.

Medications- are centrally stored. There is a locked cabinet allocated for medication storage. Centrally stored medication and destruction logs are maintained. Medications reviewed appear to have been dispensed accurately.

P&I- was reviewed. LPA observed that the facility maintains a separate log for each individuals’ monies. Money counted count was not accurately reflected on the ledger.

LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguisher was recharged last year, 12/12/2023. The facility is conducting emergency disaster/fire drills monthly; last done on 05/25/2024.

Based on the information received during this visit today in the areas reviewed, four (4) deficiencies are being cited per Title 22, Division 6 of The California Code of Regulations.

This LIC 809,809D and Appeals Rights report was reviewed with the facility representative and a copy was provided.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 06/12/2024 01:15 PM - It Cannot Be Edited


Created By: Yolanda Delgado On 06/12/2024 at 12:57 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: CHUQUIMIA'S ADULT FAMILY HOME II
FACILITY NUMBER: 336408330

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA Delgado's observation and interview, the licensee did not comply with the section cited above in 4 exterior window screens are torn and 2 exterior screens missing which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/26/2024
Plan of Correction
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4
Licensee will obtain window screens and email photos to LPA by POC due date
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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3
4
Based on LPA Delgado's observation and interview, the licensee did not comply with the section cited above in no night light was observed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/26/2024
Plan of Correction
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Licensee will obtain night light and email photo to LPA by 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:Jazmond D Harris
LICENSING EVALUATOR NAME:Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 06/12/2024 01:15 PM - It Cannot Be Edited


Created By: Yolanda Delgado On 06/12/2024 at 12:57 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: CHUQUIMIA'S ADULT FAMILY HOME II
FACILITY NUMBER: 336408330

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.2(b)(1)(C)
Needs and Services Plan
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (C) The written medical assessment specified in Section 80069.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in three clients had expired medical assessment which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/26/2024
Plan of Correction
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Licensee will obtain medical assessments for clients and email copies to LPA by POC due date
Type B
Section Cited
CCR
80069(c)(1)
Client Medical Assessments
(c) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in three clients did not have current TB documentation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/26/2024
Plan of Correction
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Licensee will obtain TB examinations for clients and email proof to LPA by 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:Jazmond D Harris
LICENSING EVALUATOR NAME:Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024


LIC809 (FAS) - (06/04)
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