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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336423469
Report Date: 06/19/2024
Date Signed: 06/19/2024 11:44:30 AM

Document Has Been Signed on 06/19/2024 11:44 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:NEW DISCOVERY RESIDENTIAL SERVICES #4FACILITY NUMBER:
336423469
ADMINISTRATOR/
DIRECTOR:		DONNA WELDONFACILITY TYPE:
735
ADDRESS:903 UNION ST.TELEPHONE:
(951) 381-4130
CITY:BEAUMONTSTATE: CAZIP CODE:
92223
CAPACITY: 4CENSUS: 3DATE:
06/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Facility Manager Vivian FranciscoTIME VISIT/
INSPECTION COMPLETED:
11:50 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Sarina Ramirez and Magda Malcore conducted an unannounced required annual inspection to the facility. LPAs met with Facility Manager Vivian Francisco and discussed the purpose of the visit.

The facility is an Adult Residential Facility (ARF), level 4. The facility is an Inland Regional Center (IRC) certified vendor with a license capacity of (4) and a current census of (3). LPAs conducted an overall inspection of the facility, which included, but was not limited to, the following:

Physical Plant & Operation: Indoor and outdoor passageways are free of obstruction. The facility has no outdoor bodies of water accessible to clients in care. Facility's backyard is enclosed and gated. Indoor and outdoor activity areas are sufficient for clients in care. Client activities include walks, reading, community outings and Day program participation. The facility has sufficient lighting and is maintained at a comfortable temperature. Client bathrooms were operating in sanitary conditions. The hot water temperature in one client bathroom measured at 133 degrees F, deficiency cited. Client bedrooms have sufficient lighting and furniture in good repair. Facility has operating carbon monoxide alarms, laundry equipment and telephone service. The facility has sufficient linen and personal hygiene items for clients in care. The facility has posted in a common area client registry, client personal rights, disaster evacuation plan, emergency telephone numbers, and facility license.



Food Service: The facility has sufficient non-perishable and perishable food supply for clients in care. Sharps were kept locked, no chemicals stored in kitchen area. The facility's refrigerator temperature measured at 42 degrees F and the freezers’ temperature measured at -2 degrees F.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2024
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 06/19/2024 11:44 AM - It Cannot Be Edited


Created By: Sarina Ramirez On 06/19/2024 at 11:01 AM
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: NEW DISCOVERY RESIDENTIAL SERVICES #4
FACILITY NUMBER: 336423469

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by the hot water temperature in one client bathroom measured at 133 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/20/2024
Plan of Correction
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Licensee agrees to provide proof to LPA hot water has been regulated no less than 105 and no more than 120 degrees F
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Karen Clemons
LICENSING EVALUATOR NAME:Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/19/2024 11:44 AM - It Cannot Be Edited


Created By: Sarina Ramirez On 06/19/2024 at 11:01 AM
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: NEW DISCOVERY RESIDENTIAL SERVICES #4
FACILITY NUMBER: 336423469

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(d)
Client Records
(d) All client records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

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 staff on duty did not have access to staff files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/24/2024
Plan of Correction
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Licensee will submit proof staff has read the regulation cited above.
Type B
Section Cited
CCR
85165(f)(7)
Emergency Intervention Staff Training
(f) The administrator who will approve the continued use of a manual restraint or seclusion shall complete additional training which shall include the following: (7) Current first aid certification and current certification in the use of cardiopulmonary resuscitation (CPR).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in by staff 1,2,3,4, and 5 had expired CPR certifications which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/24/2024
Plan of Correction
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Licensee will submit proof to LPA staff and enrolled/completed CPR certification training.
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:Karen Clemons
LICENSING EVALUATOR NAME:Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2024


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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: NEW DISCOVERY RESIDENTIAL SERVICES #4
FACILITY NUMBER: 336423469
VISIT DATE: 06/19/2024
NARRATIVE
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Care & Supervision: Facility has 24 hour care staff. Staff working have criminal record clearances.

Record Review: LPAs requested staff and clients files, however staff on duty stated she will contact Facility Manger due to not having access. Deficiency cited. Review of (3) Client files were observed to be complete. Review of (5) staff files were observed. Review of (5) staff files reveal, Staff 1,2,3,4, and 5 had expired CPR certifications. Deficiency cited.

Medical Related Services: All client medication is centrally stored and kept in a locked cabinet.

Based on observations and record review, deficiencies are being cited per Title 22, Division 6 of The California Code of Regulations.

An exit interview was conducted where the Licensing reports were discussed and copies of the reports with Appeal Rights was provided to Vivian Francisco.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
LIC809 (FAS) - (06/04)
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