<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336408885
Report Date: 08/20/2024
Date Signed: 08/20/2024 05:52:58 PM

Document Has Been Signed on 08/20/2024 05:52 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:SLB INC-NATALIEFACILITY NUMBER:
336408885
ADMINISTRATOR/
DIRECTOR:		ERICA MAY NUEVAFACILITY TYPE:
735
ADDRESS:1850 NATALIE LANETELEPHONE:
(951) 780-0947
CITY:RIVERSIDESTATE: CAZIP CODE:
92506
CAPACITY: 6CENSUS: 6DATE:
08/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:40 PM
MET WITH:Andres Amante, AdministratorTIME VISIT/
INSPECTION COMPLETED:
06:10 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
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 six (6) clients reside at this facility and there are currently two (2) caregiver present. Administrator Andres Amante arrived shortly after LPA's arrival. There is an Infection Control Plan on file.

Client Records-Incident Reports/Clients Rights-Information/Dental- LPA began review of client records. Five (5) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification.

Personnel Records/Training/and Staffing- LPA began review of employee records- Five (5) 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 4/4/2026.



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: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2024
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 3
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: SLB INC-NATALIE
FACILITY NUMBER: 336408885
VISIT DATE: 08/20/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
(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 five exterior window screens are torn. The home is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured 108.0 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 and no bodies of water observed.

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 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 this year, 05/06/2024. The facility is conducting emergency disaster/fire drills monthly; last done on 08/11/2024. LPA observed two rooms were on the second floor for live-in staff, walls were not fully enclosed; it is noted on the facility sketch as a loft.

Based on the information received during this visit today in the areas reviewed, two (2) deficiencies are being cited per Title 22, Division 6 of The California Code of Regulations.

This LIC 809, 809D, Appeal Rights report was reviewed with the facility representative and a copy was provided.

LPA requested an updated sketch due to alterations to Existing Building.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 08/20/2024 05:52 PM - It Cannot Be Edited


Created By: Yolanda Delgado On 08/20/2024 at 05:22 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: SLB INC-NATALIE
FACILITY NUMBER: 336408885

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2024

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
1
2
3
4
Based on LPA Delgado's observation and interview, the licensee did not comply with the section cited above in 5 exterior window screens had tears which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/03/2024
Plan of Correction
1
2
3
4
Licensee will replace torn window screens and either email picture or invoice to LPA by POC due date.
Type B
Section Cited
CCR
80086(a)
(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
1
2
3
4
Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in two rooms were observed on the second floor for live-in staff, walls were not fully enclosed; it is noted on the facility sketch as a loft. LPA requested prior notification to CCLD about alterations to the loft in which Administrator could not provide which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/03/2024
Plan of Correction
1
2
3
4
Licensee will forward copy of prior notification to CCLD regarding alterations to the 2nd floor loft, an updated facility sketch of the building to be occupied, including floor plan which describes the capacities of the buildings for the use intended, rooms dimensions, and a designation of the rooms to be used to be emailed 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: 08/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2024


LIC809 (FAS) - (06/04)
Page: 3 of 3