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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336409399
Report Date: 03/14/2024
Date Signed: 03/14/2024 01:29:51 PM

Document Has Been Signed on 03/14/2024 01:29 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:D & D HOME IIFACILITY NUMBER:
336409399
ADMINISTRATOR:DEBORAH LEEFACILITY TYPE:
735
ADDRESS:30894 WATSON ROADTELEPHONE:
(951) 926-6949
CITY:HOMELANDSTATE: CAZIP CODE:
92548
CAPACITY: 6CENSUS: 3DATE:
03/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:58 AM
MET WITH:Deborah Lee - AdministratorTIME COMPLETED:
01:35 PM
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Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit. LPA was granted entry and met with caregiver Victoria Blount, who was informed of the purpose of the visit. Administrator Deborah Lee arrived during LPA's visit. At the time of the visit there was one (1) staff and zero (0) clients present. The clients served are adults between the ages of 18-59 specialized for the needs of consumers with severe hearing impairment. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following:

LPA observed the client bedrooms and staff room. Physical plant, floors, windows, and doors were observed to be clean and fixtures and furniture were in good repair and were present. Facility contained a backyard patio with a shaded sitting area. Facility does not have any bodies of water on the property or guns and ammunition. The sharp and dangerous objects were observed to be locked and inaccessible to clients. The smoke detector and carbon monoxide was operational and the facility contained a charged fire extinguisher located in the kitchen. Hot water temperature was recorded at 119 degree F. Facility contained PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements.



LPA observed facility kitchen had the ability and appliances to prepare food and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.

LPA reviewed two (2) staff files and training. All staff have criminal record clearance, health screening, and updated training along with CPR/First Aid Certification. Two (2) client files were reviewed, and possessed all required paperwork including Admissions Agreement, Individual Program Plan (IPP), and updated Physician's Report. LPA inspected the P&I for two (2) clients and found no discrepancies.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2024
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: D & D HOME II
FACILITY NUMBER: 336409399
VISIT DATE: 03/14/2024
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All client medication was centrally stored and locked in a cabinet located in the kitchen. LPA reviewed client medications for two (2) clients and found all medication listed on MARS and all required labeling was found to be in place.

LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing the facility's last fire and earthquake drills was conducted on 02/25/2024, which met the department requirements. LPA observed emergency supplies and first aid kit with all required items.

No deficiencies were cited at the time of the visit.

An exit interview was conducted where a copy of this report was provided to Victoria Blought.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024
LIC809 (FAS) - (06/04)
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