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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336409877
Report Date: 02/28/2022
Date Signed: 02/28/2022 02:59:25 PM

Document Has Been Signed on 02/28/2022 02:59 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:CHERRY RANCH RESIDENTIALFACILITY NUMBER:
336409877
ADMINISTRATOR:DANA WALKERFACILITY TYPE:
735
ADDRESS:11267 CHERRY AVE.TELEPHONE:
(951) 845-2413
CITY:BEAUMONTSTATE: CAZIP CODE:
92223
CAPACITY: 6CENSUS: 3DATE:
02/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:House Manager Shaniece Peek-WalkerTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Melody Brown arrived at the facility 02/28/2022 at 12:15 PM unannounced in order to complete the facility's Annual Inspection. LPA Brown met with House Manager Shaniece Peek Walker and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. Below is a summary of what was observed:

Infection Control: LPA Brown went over COVID-19 best practices for infection control and prevention with House Manager Shaniece Peek Walker and House Manager Walker reported that Mitigation Plan was submitted 01/04/2021. LPA Brown observed the facility having Covid-19 signages throughout the facility for proper hand washing procedure and social distancing. LPA Brown toured the facility's and observed that client bathrooms have paper towels and hand soap. LPA Brown requested to inspect the facility's Personal Protective Equipment (PPE) supply. LPA Brown observed the facility to have a sufficient supply of sanitizer, gloves, masks, isolation gowns but no face shields/goggles. LPA Brown will be issuing a Technical Assistance Advisory Note instead of a deficiency due it being difficult to access face shields at numerous points during the COVID-19 pandemic. LPA Brown advised the facility to look online for items missing from their PPE supply kit, as CCL and Inland Regional Center may not have these items to supply them with.

LPA Brown went over the various recommended training for facility staff with House Manager Walker in relation to COVID-19 and House Manager Walker reported that all staff were trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing of PPE.



LPA Brown inquired as to if staff have been fit tested for N95 masks, and House Manager Walker informed LPA Brown that at this time staff have not been fit tested. LPA Brown will be issuing a deficiency during today's inspection for staff not being fit tested for N95 masks due to the facility having COVID-19 positive staff recently, *** Continuation in LIC809C ***
Efren Malagon
Melody Brown
DATE: 02/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2022
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
RIVERSIDE, CA 92507
FACILITY NAME: CHERRY RANCH RESIDENTIAL
FACILITY NUMBER: 336409877
VISIT DATE: 02/28/2022
NARRATIVE
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and N95 masks needs to be worn when a client is COVID-19 positive or under observation while awaiting test results. Additionally, all clients and most staff have been vaccinated and are practicing other COVID-19 precautions, which minimize the risk of them contracting COVID-19. LPA Brown informed Administrator Walker of the Provider Information Notice (PIN) PIN-21-10-ASC which contains resources for getting staff fit tested for N95 masks.

The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and their clients for COVID-19, when and how to isolate/quarantine client, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas. The facility also has a plan in place to monitor their clients regularly for any changes in condition and to subsequently notify the client's physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses.

During the visit, LPA Brown requested staff vaccination records and on 02/28/2022 at 01:30 PM, LPA Brown observed no vaccination record for all staff at the facility. House Manager Walker contacted Licensee Adrian Walker and Licensee Walker reported that she had their staff vaccination records and Licensee Walker also confirmed that no staff vaccination record available at the facility. LPA Brown will be issuing a deficiency for failure to keep records of Worker’s Vaccination which can pose potential risk to clients in care


An exit interview was conducted with House Manager Shaniece Peek Walker and a copy of this report (LIC809), LIC 809-D's, LIC9102 AN Technical Assistance Advisory Notes and Appeal Rights were provided.
SUPERVISOR'S NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 02/28/2022 02:59 PM - It Cannot Be Edited


Created By: Melody Brown On 02/28/2022 at 01:15 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: CHERRY RANCH RESIDENTIAL
FACILITY NUMBER: 336409877

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
130
LIcensee has provided all staff who are working with Covid 19 positive residents with fit testing for N95 respirators. This practice has a health and safety impact that includes, but is not limited to personal rights, buildings and grounds, and responsibility for providing care and supervision.

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 in by not providing all staff with fit testing for N95 respirators which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/21/2022
Plan of Correction
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Licensee stated that all staff will be provided fit testing for N95 respirator by POC due date and will submit proof of completion 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: 02/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2022


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 02/28/2022 02:59 PM - It Cannot Be Edited


Created By: Melody Brown On 02/28/2022 at 02:34 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
RIVERSIDE, CA 92507

FACILITY NAME: CHERRY RANCH RESIDENTIAL
FACILITY NUMBER: 336409877

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
121125,120140,120276


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 ensuring the personal rights of persons in care to live in a safe, healthy, comfortable home failed to comply with reporting and personnel requirements and engaged in conduct inimical to the health, welfare, and safety of persons in care in that licensee did not verify, worker's vaccination, booster or exempotion status or unvaccinated worker's test results as applicable by maintaining a record as required by State Public Officer Order of December 22, 2021 which posesposed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/07/2022
Plan of Correction
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Licensee stated to submit proof of vaccination to LPA Brown by POC due date and will also update all staff vaccination file at the facility 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: 02/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2022


LIC809 (FAS) - (06/04)
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