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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336411344
Report Date: 10/17/2023
Date Signed: 10/31/2023 02:19:44 PM

Document Has Been Signed on 10/31/2023 02:19 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
, CA 92507
FACILITY NAME:BROKEN ARROW HOMEFACILITY NUMBER:
336411344
ADMINISTRATOR:DEBORAH STANGELFACILITY TYPE:
735
ADDRESS:2984 BROKEN ARROW STREETTELEPHONE:
(951) 738-8444
CITY:NORCOSTATE: CAZIP CODE:
92860
CAPACITY: 5CENSUS: 1DATE:
10/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Shanay Waters, General ManagerTIME COMPLETED:
11:30 AM
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0905: Licensing Program Analyst (LPA) Amy Goldenberg arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction, visit purpose and provided the facility caregiver with LPA identification and business card. LPA learned there is one client residing in the home.

0935: Resident Records/Incident Reports/Personal Rights/Residents with Special Needs/Incidental Medial and Dental- LPA reviewed one client record. LPA reviewed for admission agreement, medical assessment and TB test results, consent forms, identification and emergency information, appraisal needs and service plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. Records were complete. P&I ledgers were reviewed and money counted. Accurate ledgers are maintained.

0950: Physical Plant and Safety of Environment/Operational Requirements/Food Service: LPA toured the facility inside and outside. LPAs observe the facility to be clean and in good repair. The home is maintained at a comfortable temperature. Lighting is sufficient for safety and comfort. Water temperature measured 105.0 degrees F. Grab bars, non slip mats are present in the restrooms. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals. All outdoor and indoor passageways are free of obstruction. Night lights and emergency lighting is present. A locked area is provided for medications and sharp objects. There is a telephone working at this location. The LIC 610E, emergency disaster plan is maintained. The facility has a current written definitive plan of operation. Food prep areas are clean and organized. Food supply meets the requirement of one week supply of perishable and 2 day supply of non-perishables food on hand. Food prep areas are clean and organized. Food supply meets the requirement of one week supply of nonperishable and 2 day supply of perishables food on hand.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2023
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
, CA 92507
FACILITY NAME: BROKEN ARROW HOME
FACILITY NUMBER: 336411344
VISIT DATE: 10/17/2023
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1030: Personnel Records/Training/and Staffing- LPA reviewed three employee records. CPR and annual training requirements have been met. The facility employs enough staff to maintain cleanliness and meet the needs of the clients in care.

One Staff interview was conducted. There were no clients home at time of visit.

LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. The facility has not exceeded its capacity limitation and the structure remains unchanged according to the approved floor plan. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguishers are tested or replaced annually, last done so on 11/13/2022. The facility is conducting emergency disaster and fire drills, last done on 09/05/23 was a fire drill.

Based on the information received during this visit today, there are no deficiencies being cited per Title 22, Division 6 of The California Code of Regulations.

This report was reviewed with and a copy was provided to the facility representative.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023
LIC809 (FAS) - (06/04)
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