336412373-8-29-2023-18-AS-JROO-CU2UES-20230724153136

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336412373
Report Date: 07/24/2023
Date Signed: 08/29/2023 10:06:23 AM

Document Has Been Signed on 08/29/2023 10:06 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	JOHN, TRACI, & CO		FACILITY NUMBER:	336412373
ADMINISTRATOR:	SCHWAB, TRACI		FACILITY TYPE:	735
ADDRESS:	3680 ANCHORAGE ST.		TELEPHONE:	(951) 392-2213
CITY:	HEMET	STATE: CA	ZIP CODE:	92545
CAPACITY: 5		CENSUS: 4	DATE:	07/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:50 PM
MET WITH:	Administrator Traci Schwab		TIME COMPLETED:	03:45 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

On 7/24/2023, at 1:50 p.m., Licensing Program Analyst (LPA) Janette Romero arrived unannounced at the facility to conduct an annual required visit. LPA was greeted and granted entry by Facility Manager Victoria Inniss who was informed of the purpose of visit. Licensee Traci Schawb was at the facility during the visit. The facility is made up of four (4) client bedrooms and two (2) bathrooms. The facility is approved for four (4) ambulatory clients and one (1) non-ambulatory client. During the visit, there was one (1) staff present and LPA was informed clients were at day program.

LPA conducted a tour of the facility’s interior and exterior and observed the following:

Kitchen: LPA toured the kitchen and observed kitchen to be clean. Food is stored in a safe and healthful manner. LPA observed the facility met the requirement for a 2-day supply of perishable food and 7-day of non-perishable food items. Knives/sharp instruments are secured in a locked kitchen cabinet.

Dining and Living room: LPA toured the dining and living/family room area. LPA observed living room furniture in good condition. Fire extinguisher is charged and mounted on living room wall.

Hallway: LPA toured the hallway and observed hallway to be clean with no pathway obstruction. Carbon monoxide & smoke detectors were tested and functioning properly.

Continued on LIC809-C..

*This report is an amended version of the original report.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023

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 3

Document Has Been Signed on 08/29/2023 10:04 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 08/01/2023 02:27 PM

Created By: Janette Romero On 07/24/2023 at 03:10 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: JOHN, TRACI, & CO	FACILITY NUMBER: 336412373
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85088(c)(1)

Fixtures, Furniture, Equipment, and Supplies

(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (1) An individual bed, except that couples shall be allowed to share one double or larger sized bed, maintained in good repair, and equipped with good bed springs, a clean mattress and pillow(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above due to LPA observing a urine-stained mattress utilized by Client #1, which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/03/2023
	Plan of Correction
1 2 3 4	Licensee replaced urine-stained mattress with a clean mattress during 7/24/2023 visit. *This report is an amended version of the original report.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 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:

Joel Esquivel

LICENSING EVALUATOR NAME:

Janette Romero

LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: JOHN, TRACI, & CO	FACILITY NUMBER: 336412373
	VISIT DATE: 07/24/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Centrally Stored Medications: LPA observed a first aid kit with required components. Medications were secured in a locked kitchen cabinet. LPA reviewed physical medications for Client 1 (C1) and Client 2 (C2) as well as their Medication Administration Record. LPA did not discover any discrepancies.

Bedrooms: Client bedrooms were each furnished with a bed, chair, closet, clothing storage and lighting. LPA was informed that although C1 has control of their bladder and bowel movements, C1 occasionally has bladder accidents on C1's bed. During a tour of C1’s bedroom, LPA observed urine stains on C1’s mattress. Deficiency issued.

Bathrooms: Bathrooms had a working toilet, hand wash basin and shower. The facility has clean towels, blankets, and linen, available in different colors for clients in care.

Laundry/Garage: LPA observed laundry room and garage to be clean. Washing machine and dryer are in good repair. Emergency food supplies, water, hygiene supplies, and cleaning solutions are stored in the garage.

Records: Staff present have a criminal record clearance on file and are associated to the facility. Staff training is up to date.

Yard/Outside Area: Covered patio seating is available for the residents. A brick wall secured the entire backyard. All outdoor pathways were free of obstructions. No bodies of water were observed. There were no firearms or ammunition observed at the facility, and LPA was informed the facility will not store firearms or ammunition on the premises.

Based on observations made during today’s visit, LPA cited for the urine-stained mattress faulting the facility. An exit interview was conducted, and a copy of this report was reviewed and provided to Licensee Schwab along with an LIC809-D and Appeals Rights.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3