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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336408402
Report Date: 11/21/2023
Date Signed: 11/21/2023 11:14:27 AM

Document Has Been Signed on 11/21/2023 11:14 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:JUDAH HOUSEFACILITY NUMBER:
336408402
ADMINISTRATOR:CASSANDRA KNIGHTENFACILITY TYPE:
735
ADDRESS:13400 CHAPARRAL ROADTELEPHONE:
(951) 378-3800
CITY:CABAZONSTATE: CAZIP CODE:
92230
CAPACITY: 5CENSUS: 4DATE:
11/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Raven Johnson, ManagerTIME COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced required 1-year visit to the facility. LPA met with Raven Johnson, Manager and discussed the purpose of the visit.

The facility is an Adult Residential Facility (ARF), license capacity of (5) with a current census of (4) clients. During LPA visit, (1) staff and (1) client were present at the facility. LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:

Physical Plant: Indoor and outdoor passageways are free of obstruction. The facility has no bodies of water. The facility has sufficient lighting and is maintained at a comfortable temperature. Client bathrooms were operating in safe and sanitary conditions. The hot water temperature in clients bathrooms measured at 105 degrees F. Client bedrooms have sufficient lighting and furniture in good repair. The facility has operating carbon monoxide alarms and telephone service. The facility has sufficient linen, towels, and personal hygiene items for clients. The facility has posted in a common area, facility license, house rules, emergency disaster plan and telephone numbers.


Food Service: Facility has sufficient non-perishable and perishable food supply for clients in care. The refrigerator and freezer are operating in a healthful manner. Pesticides and other cleaning solutions were kept locked and stored away from food areas.
Care & Supervision: Facility has 24-hour/7 days a week care staff. Staff working have criminal record clearances or exemptions through the Department.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2023
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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: JUDAH HOUSE
FACILITY NUMBER: 336408402
VISIT DATE: 11/21/2023
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Record Review: (3) staff files reviewed were observed to be complete. (3) client files were reviewed. Client files review reveals the Licensee did not maintain copies of tuberculosis results for client#1 (C1) and client#2 (C2) on file.
Medical Related Services: All medication is centrally stored and kept in a locked in a cabinet.

Based on observations and record review, a deficiency is being cited per Title 22, Division 6 of The California Code of Regulations.

An exit interview was conducted with Manager Johnson where reports (LIC809/LIC809-D) were discussed. Copies of the reports with appeal rights was provided to the Manager at the conclusion of the visit.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/21/2023 11:14 AM - It Cannot Be Edited


Created By: Magda Malcore On 11/21/2023 at 10:36 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: JUDAH HOUSE
FACILITY NUMBER: 336408402

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Client Medical Assessments
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 observations, the licensee did not comply with the section cited above by Licensee did not maintain copies of tuberculosis results for client #1 (C1) and client #2(C2) on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/15/2023
Plan of Correction
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Licensee shall submit to the Licensing Agency proof of tuberculosis results 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:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2023


LIC809 (FAS) - (06/04)
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