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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336408402
Report Date: 05/10/2024
Date Signed: 05/10/2024 10:23:03 AM

Document Has Been Signed on 05/10/2024 10:23 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/
DIRECTOR:		CASSANDRA KNIGHTENFACILITY TYPE:
735
ADDRESS:13400 CHAPARRAL ROADTELEPHONE:
(951) 378-3800
CITY:CABAZONSTATE: CAZIP CODE:
92230
CAPACITY: 5CENSUS: 4DATE:
05/10/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Raven Johnson - ManagerTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Magda Malcore conducted a case management visit based on observations made during complaint #56-AS-20240411161017 investigation. LPA met with Raven Johnson, Manager, and discussed the purpose of the visit.

On 5/10/24, LPA arrived at the facility and observed in the backyard of the facility a broken fence which gave access to an open field area. Manager Johnson stated that the fence is scheduled to be repaired on Monday, 5/13/24.

Based on LPA observations, a deficiency is being cited per Title 22 of the California Code of Regulations.

An exit interview was conducted where this report and report LIC809-D was discussed and copies with appeal rights were provided to Manager Johnson at the conclusion of the visit.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2024
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 05/10/2024 10:23 AM - It Cannot Be Edited


Created By: Magda Malcore On 05/10/2024 at 10:05 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: 05/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/24/2024
Section Cited
CCR
80087(a)

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(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 at evidenced by:
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The Licensee shall submit to the Licensing Agency documentation of repaired fence by POC due date.
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Based on LPA observations, the Licensee did not comply with the section cited by, the backyard of the facility has broken fence which gave direct access to an open field area, which poses/posed a potential health, safety or personal rights risk to persons in care.
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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:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2024


LIC809 (FAS) - (06/04)
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