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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336408879
Report Date: 10/19/2023
Date Signed: 10/19/2023 04:57:27 PM

Document Has Been Signed on 10/19/2023 04:57 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
, CA 92507
FACILITY NAME:MENDOZA ADULT FACILITYFACILITY NUMBER:
336408879
ADMINISTRATOR:LINDA PUMAFACILITY TYPE:
735
ADDRESS:5169 CLUNY CIRCLETELEPHONE:
(951) 544-4415
CITY:RIVERSIDESTATE: CAZIP CODE:
92505
CAPACITY: 6CENSUS: 4DATE:
10/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:08 PM
MET WITH:Licensee/Administrator Christopher PumaTIME COMPLETED:
05:10 PM
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On 10/19/23, Licensing Program Analyst (LPA) Melody Brown arrived unannounced to conduct the required annual visit to the facility. LPA Brown met with staff Maria Mendoza, introduced self and stated purpose of the visit. Licensee/Administrator Christopher Puma was contacted and arrived during the visit.

The facility has 6 bedrooms, 4 bathrooms, kitchen, dining room, living room, attached garage. The facility is vendorized by Inland Regional Center (IRC). LPA Brown completed a walk-through of the facility, review of records, and P&I audit.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 74 degrees Fahrenheit. LPA Brown inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, dresser, chairs and sufficient lighting and reading lamps. LPA Brown inspected client bathrooms; bathrooms were clean, and appliances were found functional. Water temperatures tested at 115 degrees Fahrenheit. The facility is equipped with operational combined smoke detectors and carbon monoxide alarms, charged fire extinguisher, and first aid kit with first aid book. Posters such as the personal rights, CCL complaint poster, emergency disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, medications, and other dangerous items were kept in secure cabinets inaccessible to clients. LPA Brown observed Room #4 has alteration and per records review, CCL is not notified of the change. LPA Brown informed Licensee/Administrator Puma that deficiency will be issued as this pose potential health, safety, and personal rights risk to clients in care. P&I were observed locked and made inaccessible. The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility. Overall, the facility is clean, in good repair, and operates in safe conditions for clients in care.

*** Continuation in LIC809C ***

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2023
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 5
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
, CA 92507
FACILITY NAME: MENDOZA ADULT FACILITY
FACILITY NUMBER: 336408879
VISIT DATE: 10/19/2023
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Yards/Outside: A backyard was observed and an attached garage, two (2) side gate on the front of the house that leads into the backyard, one (1) Office, one (1) shed that are used for storage. All outdoor pathways were free of obstructions.

Food Service: LPA Brown observed two (2) days supply of perishable foods and seven (7) days supply of non-perishables food and snacks. Dishes, cups, and utensils were stored properly.



Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPA Brown reviewed client files for admission agreements, updated physician reports, and needs and services plans. LPA Brown also reviewed staff and administrator's file for First Aid/CPR certification, Tuberculosis (TB) Test, criminal record clearance, trainings, and health screenings. LPA Brown observed Staff #1 (S1) and Staff #2 (S2), Staff #3 (S3), Staff #4 (S4), Staff #5 (S5) and Staff #6 (S#6) without the required Tuberculosis (TB) test in their facility file. LPA Brown informed Administrator Puma that deficiency will be issued as this pose immediate health, safety and personal rights risk to clients in care. Moreover, P& I was audited, and no deficiencies observed.

Deficiencies were cited during this visit. An exit interview was conducted, where this report LIC809, LIC809C, LIC809D and Appeal Rights were discussed and copies were provided to Administrator, Christopher Puma.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 10/19/2023 04:57 PM - It Cannot Be Edited


Created By: Melody Brown On 10/19/2023 at 04:24 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
, CA 92507

FACILITY NAME: MENDOZA ADULT FACILITY
FACILITY NUMBER: 336408879

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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 observation, interview and record review, the licensee did not comply with the section cited above by not having Staff #1 (S1), Staff #2 (S2), Staff #3 (S3), Staff #4 (S4), Staff #5 (S5) and Staff #6 (S6) Tuberculosis (TB) Test in their facility file which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/20/2023
Plan of Correction
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Licensee stated to submit proof of TB Test Appointments/Result for S1, S2, S3, S4, S5, S6 to LPA Brown by POC due date.
Licensee stated to submit Signed Statement of Understanding on CCR 80066(a)(11) to LPA Brown by POC due date.
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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 10/19/2023 04:57 PM - It Cannot Be Edited


Created By: Melody Brown On 10/19/2023 at 04:34 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
, CA 92507

FACILITY NAME: MENDOZA ADULT FACILITY
FACILITY NUMBER: 336408879

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80086(a)
80086 Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above by having alteration in Room #4 and failed to notify Community Care Licensing Division (CCLD) of the proposed change which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2023
Plan of Correction
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Licensee stated to remove the partition in Room #4 and submit proof to LPA Brown by POC due date.
Licensee stated to submit Signed Statement of Understanding on CCR 80086(a) to LPA Brown by POC due date.
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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023


LIC809 (FAS) - (06/04)
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