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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336423460
Report Date: 08/06/2024
Date Signed: 08/06/2024 02:04:22 PM

Document Has Been Signed on 08/06/2024 02:04 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:MARIA M. BLAYAFACILITY NUMBER:
336423460
ADMINISTRATOR/
DIRECTOR:		BLAYA, MARIA M.FACILITY TYPE:
735
ADDRESS:1113 SANDRA CIRCLETELEPHONE:
(951) 738-8192
CITY:CORONASTATE: CAZIP CODE:
92881
CAPACITY: 6CENSUS: 5DATE:
08/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Licensee/Administrator Maria M. BlayaTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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On 08/06/2024 at 11:15 AM, Licensing Program Analysts (LPAs) Melody Brown and Lavette Farlow conducted an unannounced visit to the facility to conduct the required comprehensive annual inspection to the facility. LPAs Brown and Farlow were greeted by a staff and gained access at the home. Licensee/Administrator Maria Blaya was called and informed of the visit. LPAs Brown and Farlow explained the purpose of the visit to Licensee/Administrator Maria Blaya.

The facility has six (6) bedrooms, seven (7) and 1/2 bathrooms, kitchen, dining room, living room, attached garage, pool and backyard. The facility is vendorized by Inland Regional Center (IRC). LPAs Brown and Farlow completed a walkthrough of the facility, review of records, medications audit and Personal and Incidental (P&I) audit .



Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD), LPAs Brown and Farlow observed one (1) client during the visit. Four (4) clients’ were out in the community. There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 78 degrees Fahrenheit. LPAs Brown and Farlow inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting. LPAs Brown and Farlow inspected client bathrooms; bathrooms were clean, and appliances were found functional. Water temperatures tested at 111 degrees Fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide detectors, charged fire extinguisher, and first aid kit with first aid book.

Posters such as; the personal rights, CCLD complaint poster, labor laws, and emergency disaster plan were posted in a common area. Client medications were kept in secure cabinets inaccessible to clients. LPAs Brown and Farlow observed motion detected lights in the clients bathrooms. The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility.
*** Continuation in LIC809C ***
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2024
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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Document Has Been Signed on 08/06/2024 02:04 PM - It Cannot Be Edited


Created By: Melody Brown On 08/06/2024 at 01:24 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
, CA 92507

FACILITY NAME: MARIA M. BLAYA
FACILITY NUMBER: 336423460

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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 observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that Staff #2 (S2) complete the required Health Screening Report which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/07/2024
Plan of Correction
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LIcensee stated to submit medical appointment for S2 to complete the required Health Screening Report to LPA Brown on Plan of Correction (POC) due date.
Type A
Section Cited
CCR
80066(a)(11)
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: (11) Tuberculosis test documents as specified in Section 80065(g).

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 Staff #2 (S2) complete the required Tuberculosis (TB) Test Result which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/07/2024
Plan of Correction
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Licensee stated to submit medical appointment for S2 to complete the required TB Test to LPA Brown on 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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 08/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2024


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: MARIA M. BLAYA
FACILITY NUMBER: 336423460
VISIT DATE: 08/06/2024
NARRATIVE
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Yards/Outside: Three shaded patio, two (2) side gate with self-latching handle on the left and right side of the house that leads into the backyard, attached four (4) car garage observed. All outdoor pathways were free of obstructions. A pool with the required fenced were observed and locked.

Food Service: LPAs Brown and Farlow 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 and Farlow reviewed three (3) client files for admission agreements, medical assessments/physician reports, and Individual Program Plan (IPP). LPAs Brown and Farlow observed files reviewed were complete. LPAs Brown and Farlow also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test result. LPAs Brown and Farlow observed that Staff #2 (S2) does not have Health Screening Report in S2 file. Deficiency will be issued. Also, LPAs Brown and Farlow noted that S2 does not have Tuberculosis Test Result maintained in S2 file. Deficiency will be issued. .

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

Two (2) Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, and Appeal Rights were discussed, and copies were provided to Licensee/Administrator Maria Blaya.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
LIC809 (FAS) - (06/04)
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