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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336409883
Report Date: 09/18/2024
Date Signed: 09/18/2024 02:49:14 PM

Document Has Been Signed on 09/18/2024 02:49 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:GRANDVIEW HOMEFACILITY NUMBER:
336409883
ADMINISTRATOR/
DIRECTOR:		CARMEN GONZALEZFACILITY TYPE:
735
ADDRESS:19163 CONSUL AVE.TELEPHONE:
(951) 279-5517
CITY:CORONASTATE: CAZIP CODE:
92881
CAPACITY: 4CENSUS: 3DATE:
09/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:50 PM
MET WITH:Carmen GonzalezTIME VISIT/
INSPECTION COMPLETED:
02:55 PM
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On 09/18/2024 at 12:50 PM, Licensing Program Analysts (LPAs) Melody Brown, Eldin Serrano and Raquel Hernandez conducted an unannounced visit to the facility to conduct the required comprehensive annual inspection. LPAs Brown, Serrano and Hernandez were greeted by Licensee/Administrator Carmen Gonzalez and gained access at the home. LPAs Brown, Serrano and Hernandez explained the purpose of the visit to Licensee/Administrator Carmen Gonzalez .

The facility has three (3) bedrooms, two (2) bathrooms, kitchen, dining room, living room, no garage, TV room and backyard. The facility is Adult Residential Facility (ARF) level 2 and vendorized by Inland Regional Center (IRC). The facility are licensed for 4 of which can be ambulatory. LPAs Brown, Serrano and Hernandez completed a walkthrough of the facility, review of records, Personal and Incidental (P&I) and medications audit.



Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD), LPAs Brown, Serrano and Hernandez observed no client during the visit as Licensee/Administrator Gonzalez reported that all 3 clients are out in the community. There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 77 degrees Fahrenheit. LPAs Brown, Serrano and Hernadez inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, chairs, and sufficient lighting. LPAs Brown, Serrano and Hernandez inspected client bathrooms; bathrooms were clean, and appliances were found functional. Water temperatures tested at 108 degrees Fahrenheit. The facility is equipped with operational combined smoke detectors and carbon monoxide detectors, charged fire extinguisher, and first aid kit with first aid book. In addition, LPAs Brown, Serrano and Hernandez observed non-slip mat on client’s bathroom.
*** Continuation in LIC809C ***
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE: DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/18/2024
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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: GRANDVIEW HOME
FACILITY NUMBER: 336409883
VISIT DATE: 09/18/2024
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During the tour of the facility, LPAs observed that part of the family room was converted to a TV room. Per review and interviews with staffs LPAs noted that alterations were made to the facility and no building permit was secured and no information was provided to CCLD for the alterations made at the facility. Deficiency will be issued. Moreover, posters such as the personal rights, CCLD complaint poster, and emergency disaster plan were posted in a common area. Client medications were kept in secure cabinets inaccessible to clients. LPAs Brown, Serrano and Hernandez observed no night lights at the hallway leading to clients' shared bathrooms. Deficiency will be issued. The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility.

Yards/Outside: One shaded patio, one (1) side gate with self-latching handle on the left side of the house that leads into the backyard, car garage observed converted to gym room. All outdoor pathways were free of obstructions.

Food Service: LPAs Brown, Serrano and Hernandez observed two (2) day(s) supply of perishable food and seven (7) day(s) supply of non-perishables food and snacks. Dishes, cups, and utensils were stored properly.


Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPAs Brown, Serrano and Hernandez reviewed three (3) client files for admission agreements, medical assessments/physician reports, centrally stored medication lists and Individual Program Plan (IPP). LPAs Brown, Serrano and Hernandez observed files reviewed were complete. LPAs Brown, Serrano and Hernandez also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test result and LPAs observed no issue.

LPAs Brown, Serrano and Hernandez audited three (3) clients’ medications and no issues were observed. LPAs Brown, Serrano and Hernandez audited three (3) client's Personal and Incidental (P&I) and no issues observed.

Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809D, and Appeal Rights were discussed, and copies were provided to Licensee/Administrator Carmen Gonzalez.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/18/2024 02:49 PM - It Cannot Be Edited


Created By: Eldin Serrano On 09/18/2024 at 02:23 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: GRANDVIEW HOME
FACILITY NUMBER: 336409883

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(e)(2)
Fixtures, Furniture, Equipment, and Supplies
(e) Emergency lighting, which shall include at a minimum working flashlights or other battery-powered lighting, shall be maintained and readily available in areas accessible to clients and staff. (2) Night lights shall be maintained in hallways and passages to nonprivate bathrooms.

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 that night lights were maintained in hallways and passages to non private bathrooms which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/27/2024
Plan of Correction
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Licensee stated to obtain/purchase the required night lights and submit to LPA Serrano on plan of correction (POC) due date.
Type B
Section Cited
CCR
80086(c)
80086 Alterations to Existing Buikding or New Facilities (c) Prior to construction or altrerations, state or local law requires that all facilities secure a building permit.

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 securing a building permit for the alteration made at the facility as evidenced of part of the family room converted to a TV room, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2024
Plan of Correction
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Licensee stated to obtain the required building permit for the alterations made at the facility and submit proof to LPA Serrano by the plan of correction (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:Eldin Serrano
LICENSING EVALUATOR SIGNATURE:
DATE: 09/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2024


LIC809 (FAS) - (06/04)
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