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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336409877
Report Date: 02/29/2024
Date Signed: 02/29/2024 02:20:06 PM

Document Has Been Signed on 02/29/2024 02:20 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
SAN BERNARDINO, 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:
02/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Jennifer UlloaTIME COMPLETED:
02:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced required 1-year visit to the facility. LPA met with Jennifer Ulloa, facility representative, and discussed the purpose of the visit.

The facility is an Adult Residential, 4i, facility. The facility has a license capacity of (6) ambulatory clients and a current census of (3) clients. During today's inspection, two (2) staff and one client were present at the facility. LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:

Physical Plant: LPA observed indoor and outdoor passageways are kept free of obstructions. The facility has sufficient indoor and outdoor space for client activities. The facility has no bodies of water. The facilities is enclosed with latched gates. The facility is maintained at a comfortable temperature. Client bedrooms were equipped with furniture in good repair, sufficient bed linen and lighting. Client bathroom shower, faucets, and toilet were operating properly. Bathroom hot water temperature tested at 117 degrees F. The facility has sufficient activity supplies for clients and client activities include community outings and day program participation. The facility has sufficient linen, personal hygiene products, and furniture for clients in care. The facility has operating telephone service, fire/carbon monoxide alarms, and laundry equipment. Cleaning supplies, and sharps were kept locked and inaccessible to clients in care.

Food Service: The facility has sufficient non-perishable and perishable food for number of clients in care. The refrigerator and freezer where operating in a healthful manner. The facility has sufficient cups, plates, and utensils for client use.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/29/2024
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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CHERRY RANCH RESIDENTIAL
FACILITY NUMBER: 336409877
VISIT DATE: 02/29/2024
NARRATIVE
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Care & Supervision: Facility has care staff coverage 24 hours a day, 7 days a week.

Record Review: The facility's last earthquake drill was conducted on 1/29/24. The Administrator's certification expires on 12/05/2025. LPA review of three (3) client files reveals, the facility did not maintain current Individual Program Plans (IPP's) for client 1 (C1), client 2 (C2), and client 3 (C3) on file. C1's IPP on file was dated 10/04/2021. C2's IPP on file was dated 1/11/2022, C3's IPP on file was dated 10/04/2021. Deficiency cited. LPA staff record review reveals, staff records were not maintained at the facility, including record of staff's background clearance, first aid training, and health screening with tuberculosis results. Interview with staff reveals, staff records were currently off-site being update and staff did have access to them. Deficiency cited.

Health Related Services: Medications are centrally stored. LPA observed medications were kept in a room inaccessible to clients in care. The facility has a first aid kit and manual for health services.

Deficiencies are being cited per Title 22, Division 6 of The California Code of Regulations.

An exit interview was conducted where the Licensing report were discussed and copies of the reports with Appeal Rights were provided to the facility representative as the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 02/29/2024 02:20 PM - It Cannot Be Edited


Created By: Magda Malcore On 02/29/2024 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: 02/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Personnel Records
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
Type B
Section Cited
CCR
80066(a)(10)
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: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA record review, the licensee did not comply with the section cited above by not having record of staffs health screening with tuberculosis results on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/14/2024
Plan of Correction
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The Licensee shall submit to the Licensing agency documentation of (4) staff health screening with tuberculosis results 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:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 02/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/29/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 02/29/2024 02:20 PM - It Cannot Be Edited


Created By: Magda Malcore On 02/29/2024 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: 02/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(12)(B)
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: (12) For employees that are required to be fingerprinted pursuant to Section 80019: (B) Documentation of either a criminal record clearance or exemption as required by Section 80019(e).

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
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Based on LPA record review, the licensee did not comply with the section cited above by not maintaining record of staff's criminal record documentation on file; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/14/2024
Plan of Correction
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3
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The Licensee shall submit to the Licensing Agency proof of four (4) staff current criminal record statements and clearance/exemption documentation by POC due date.
Section Cited
Personnel Records
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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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:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 02/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/29/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 02/29/2024 02:20 PM - It Cannot Be Edited


Created By: Magda Malcore On 02/29/2024 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: 02/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA record review, the licensee did not comply with the section cited above by not maintaining record of staff's first aid training on file; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/14/2024
Plan of Correction
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The Licensee shall submit to the Licensing Agency proof of four (4) staffs current first aid training by POC due date.
Type B
Section Cited
CCR
80068.3(a)
Modifications to Needs and Services Plan
(a) The licensee shall ensure that each client's written Needs and Services Plan is updated as often as necessary to assure its accuracy, but at least annually. These modifications shall be maintained in the client's file.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review, the licensee did not comply with the section cited above by not maintaining record of three (3) clients current annual IPP on file; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/14/2024
Plan of Correction
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2
3
4
The Licensee shall submit to the Licensing Agency proof of client's current annual IPP 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:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 02/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/29/2024


LIC809 (FAS) - (06/04)
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