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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336423458
Report Date: 05/09/2023
Date Signed: 05/10/2023 08:17:21 AM

Document Has Been Signed on 05/10/2023 08:17 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ALPHA CHRISTIAN HOMES IIFACILITY NUMBER:
336423458
ADMINISTRATOR:AURELIO P. BESINAFACILITY TYPE:
735
ADDRESS:1028 PAINTBRUSH TRAILTELEPHONE:
(951) 282-2938
CITY:HEMETSTATE: CAZIP CODE:
92545
CAPACITY: 6CENSUS: 4DATE:
05/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Jorgena Lavarez, House Manager TIME COMPLETED:
04:00 PM
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Licensing Program Analysts (LPA's ) Yolanda Delgado and Kathleen Banrasavong arrived unannounced to conduct an annual inspection. Upon arrival LPA's was greeted by facility staff and granted entry. LPA's began inspection with introduction and visit purpose. Upon arrival LPA's learned that four (4) clients reside at this facility and there are currently two (2) caregiver present. House Manager, Jorgena Lavarez arrived during the visit. There is not an Infection Control Plan on file.

Client Records-Incident Reports/Clients Rights-Information/Dental- LPA began review of client records. Four (4) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification.

Personnel Records/Training/and Staffing- LPAs began review of employee records- Two (2) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening (missing from one (1) file) and TB test results, employee rights, training verification, and current administrator certification; expiration date 1/24/2024.



Food Service- Food prep areas are clean and organized. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a locked location for chemicals and sharps in the kitchen.

(Continued on LIC809C)
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2023
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
RIVERSIDE, CA 92507
FACILITY NAME: ALPHA CHRISTIAN HOMES II
FACILITY NUMBER: 336423458
VISIT DATE: 05/09/2023
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(Continuation from LIC809)

Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. LPA observed the facility to be clean and in good repair; except for one (1) window screen missing. The home is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured 105.0 degrees F. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. The LIC 610, emergency disaster plan is maintained. There are no firearms at this home. This home does not have a pool.

Medications- are centrally stored. There is a locked cabinet allocated for medication storage. Centrally stored medication and destruction logs are maintained. Medications reviewed appear to have been dispensed accurately.

P&I- was reviewed. LPA observed that the facility maintains a separate log for each individuals’ monies. Money counted count was accurately reflected on the ledger.

LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguisher was recharged, 10/22/2022. The facility is conducting emergency disaster/fire drills monthly; last one done on 04/15/2023.

Based on the information received during this visit today in the areas reviewed, two (2) deficiencies and one (1) Technical Advisory (TA) are being cited per Title 22, Division 6 of The California Code of Regulations.

This LIC 809, 809D, TA, Appeal rights reports was reviewed with the facility representative and a copy will be emailed and a request of confirmation receipt will be requested.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/10/2023 08:17 AM - It Cannot Be Edited


Created By: Yolanda Delgado On 05/09/2023 at 03:38 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: ALPHA CHRISTIAN HOMES II
FACILITY NUMBER: 336423458

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's Delgado and Banrasavong observation abd interview, the licensee did not comply with the section cited above in window screen is missng from client bedroom #1 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/16/2023
Plan of Correction
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Licensee will obtain a window screen and send a photo by email to LPA Delgado by POC Due date.
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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Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in Administrator's health screening is missing from personnel file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/16/2023
Plan of Correction
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Licensee will obtain health screening from HR and place in file and send photo to LPA Delgado 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:Jazmond D Harris
LICENSING EVALUATOR NAME:Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2023


LIC809 (FAS) - (06/04)
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