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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336411344
Report Date: 10/28/2024
Date Signed: 10/28/2024 02:00:04 PM

Document Has Been Signed on 10/28/2024 02:00 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:BROKEN ARROW HOMEFACILITY NUMBER:
336411344
ADMINISTRATOR/
DIRECTOR:		DEBORAH STANGELFACILITY TYPE:
735
ADDRESS:2984 BROKEN ARROW STREETTELEPHONE:
(951) 738-8444
CITY:NORCOSTATE: CAZIP CODE:
92860
CAPACITY: 5CENSUS: 4DATE:
10/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Administrator Shanay Waters TIME VISIT/
INSPECTION COMPLETED:
02:05 PM
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Licensing Program Analyst (LPA) Raquel Hernandez made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Staff Angela Perez and was granted entry to the facility. At the time of the visit there was two (2) staff present, and two (2) clients present. The facility is a five (5) bedroom, two (2), bathroom home, with a kitchen/dining area, living room, and attached garage. The facility is an Adult Residential (ARF) Facility Level 4i home Vendorized by Inland Regional Center Licensed capacity is (5) current census (4). LPA was accompanied by staff Angela Perez, to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected clients bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperatures in the bathrooms to be 107 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. There was a designated storage space for client/staff files. Medications are kept inside medication cabinet inaccessible to clients in care. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care.

Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2024
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: BROKEN ARROW HOME
FACILITY NUMBER: 336411344
VISIT DATE: 10/28/2024
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Record Review: LPA reviewed four (4) client files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed two (2) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. Medications were audited at random and appeared to be dispensed appropriately by staff members. P&I funds were counted for and matched with the ledger.

Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809) was discussed and provided to Administrator Shanay Waters.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024
LIC809 (FAS) - (06/04)
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