336409399-3-20-2023-18-AS-JARA-CQ526A-20230320170650

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336409399
Report Date: 03/20/2023
Date Signed: 03/20/2023 05:07:01 PM

Document Has Been Signed on 03/20/2023 05:07 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:	D & D HOME II		FACILITY NUMBER:	336409399
ADMINISTRATOR:	DEBORAH LEE		FACILITY TYPE:	735
ADDRESS:	30894 WATSON ROAD		TELEPHONE:	(951) 926-6949
CITY:	HOMELAND	STATE: CA	ZIP CODE:	92548
CAPACITY: 6		CENSUS: 3	DATE:	03/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Administrator, Deborah Lee-Eberflus		TIME COMPLETED:	05:15 PM

NARRATIVE

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Licensing Program Analysts (LPAs) Janira Arreola and Sara Martinez conducted an unannounced annual required visit on 3/20/2023 at 03:30 p.m. LPA was granted entry and met with Administrator, Deborah Lee-Eberflus who was informed of the purpose of the visit. At the time of the visit there was (3) staff and (3) clients present.

The facility is a one story home with (5) bedrooms and (3) bathrooms. The clients served are adults between the ages of 18-59. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted staff and interviews. LPA observed the following:

Infection Control: The LPA observed the hand washing stations in the facility restrooms had the hand washing signs with the steps on how to properly wash hands. LPA observed gloves and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan and found all required infection control measures.

Physical Plant: LPA observed the client bedrooms. Physical plant, floors, windows, and doors were observed to need more consistent cleaning as the LPAs observed that the facility had clutter throughout in the kitchen, backyard, and living areas. The LPAs noted the facility was odoriferous upon entering the facility and in the facility backyard. Fixtures and furniture were present, and in good repair.This will be documented on a technical advisory note. LPAs observed the facility outdoor furniture for clients to sit outdoors. Laundry room was observed and was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to clients.

Food Service: LPA observed facility kitchen had the ability to prepare food and possessed equipment in good working condition. The facility met the 2-day perishable and 7-day non-perishable food requirement.

Care & Supervision/Administration: Adequate staff are present for the supervision of clients. Emergency exiting plans, telephone numbers and personal rights were found posted in the facility. The listed administrator, possesses a current administrator's certificate.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023

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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: D & D HOME II	FACILITY NUMBER: 336409399
	VISIT DATE: 03/20/2023

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Record Review and Resident/Staff Files: LPA reviewed (2) staff files and (2) client files.All staff have criminal clearance and updated training along with CPR/First Aid Certification. Two (2) client files were reviewed, and possessed all required paperwork, except for the needs and services plan. LPA will document type B deficiency for this along with the plan of correction.

Health Related Services/ Incidental Medical Services: All client medication was locked in a medication cabinet. LPA reviewed client medications for (2) clients and found all medication listed on centrally stored lists and all required labeling was found to be in place.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA was informed that the facility had conducted a fire drill as required with the fire alarm inspection conducted on 3/11/2023. LPA observed all facility exits were clear from obstructions.

An exit interview was conducted where a copy of this report along with LIC809-D pages, and appeal rights, were provided to Administrator, Deborah Lee-Eberflus..

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/20/2023 05:07 PM - It Cannot Be Edited

Created By: Janira Arreola On 03/20/2023 at 04:45 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: D & D HOME II	FACILITY NUMBER: 336409399
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85068.3(a)

Modifications to Needs and Services Plan

(a) The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental and/or social functioning. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based onrecord review, the licensee did not comply with the section cited above with (2) client files that did not have needs and services plan for LPAs to review at the time of the visit. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/28/2023
	Plan of Correction
1 2 3 4	Administrator agree to send the LPA the needs and services plan for both clients reviewed files by the POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Joel Esquivel

LICENSING EVALUATOR NAME:

Janira Arreola

LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023

LIC809 (FAS) - (06/04)

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