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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336423469
Report Date: 05/08/2025
Date Signed: 05/08/2025 11:49:07 AM

Document Has Been Signed on 05/08/2025 11:49 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:		DORANCE L. CREIGHTON JR.FACILITY TYPE:
735
ADDRESS:903 UNION ST.TELEPHONE:
(951) 381-4130
CITY:BEAUMONTSTATE: CAZIP CODE:
92223
CAPACITY: 4CENSUS: 4DATE:
05/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Administrator Assistant Dejeane HendersonTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Sarina Ramirez and Eldin Serrano conducted an unannounced required annual inspection to the facility. LPAs met with Administrator Assistant Dejeane Henderson and discussed the purpose of the visit.

The facility is an Adult Residential Facility (ARF), level 4i. The facility is an Inland Regional Center (IRC) certified vendor with a license capacity of (4) and a current census of (4). 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 swimming pools or similar bodies of water. Facility's backyard is enclosed and gated. Indoor and outdoor activity areas are sufficient for clients in care. Client activities include community outings, day program participation, coloring, puzzles, and walks. The facility has sufficient lighting and is maintained at a comfortable temperature. Client bathrooms were operating in sanitary conditions. The hot water temperature measured at 110 and 111 degrees F. Client bedrooms have sufficient lighting and furniture in good repair, , however C1’s bedroom lamp is in disrepair; technical violation discussed. Facility has operating smoke detector/carbon monoxide alarms, laundry equipment and telephone service. The facility has sufficient linens and personal hygiene items for clients in care. The facility has posted in a common area emergency disaster plan and telephone numbers, facility license, weekly menu, facility sketch, client roster, CCLD complaint poster, and personal rights.



Food Service: The facility has sufficient non-perishable and perishable food supply for clients in care. Sharps and chemicals were kept locked inaccessible to clients in care.
**** Continuation on LIC 809 – C****
NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Sarina Ramirez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/08/2025
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 7
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 05/08/2025
NARRATIVE
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Care & Supervision: Facility has 24 hour care staff. Staff working have criminal record clearances.

Record Review: Review of (4) Client files were observed to be incomplete, all clients did not have P&I ledgers or cash available for LPAs to review; deficiency issued. Review of (2) staff files were observed to be incomplete, S1 and S2 did not have CPI certificates, deficiency issued. Staff could not provide liability insurance, deficiency issued, staff could not provide infection control plan, technical violation issued.

Medical Related Services: Client’s medications are labeled and centrally stored in a locked cabinet.

Based on observations and record review, technical violations and deficiencies were 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 Administrator Assistant Dejeane Henderson.
NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Sarina Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 05/08/2025 11:49 AM - It Cannot Be Edited


Created By: Sarina Ramirez On 05/08/2025 at 11:27 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: 05/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80026(h)(1)
Safeguards for Cash Resources, Personal Property and Valuables
(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following: (1) Records of clients' cash resources maintained as a drawing account, which shall include a current ledger accounting, with columns for income, disbursements and balance, for each client. Supporting receipts for purchases shall be filed in chronological order.

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 having P& I records avaiable for review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2025
Plan of Correction
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Administrator agreed to provide ledgers for all clients of all personal incidentials to LPA by POC due date.
Type B
Section Cited
CCR
85165(b)
Emergency Intervention Staff Training
(b) Staff who use, participate in, approve or provide visual checks of manual restraint or seclusion, shall have a minimum of sixteen hours of emergency intervention training and be certified for having successfully completed the training.

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 having CPI certificates for S1 and S2 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2025
Plan of Correction
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Administrator has agreed to provide proof of certitifcates to LPA 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.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Sarina Ramirez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/08/2025 11:49 AM - It Cannot Be Edited


Created By: Sarina Ramirez On 05/08/2025 at 11:34 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: 05/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1796.42(c)(d)
1796.42 License Posting, Insurance, and Abuse Reporting

A home care organization licensee shall do all of the following:
(c) Maintain and abide by an employee dishonesty bond, including third-party coverage, with a minimum limit of ten thousand dollars ($10,000).
(d) Maintain proof of general and professional liability insurance in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the aggregate.

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 providing proof of liability insurance or surety bond which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2025
Plan of Correction
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Administrator agreed to provide proof of insurance to LPA by POC due date.
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.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Sarina Ramirez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2025


LIC809 (FAS) - (06/04)
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