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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336423747
Report Date: 07/10/2024
Date Signed: 07/10/2024 12:08:32 PM

Document Has Been Signed on 07/10/2024 12:08 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ROSS HOUSE, THEFACILITY NUMBER:
336423747
ADMINISTRATOR/
DIRECTOR:		ROSS, TERRIFACILITY TYPE:
735
ADDRESS:41758 LAURIE LANETELEPHONE:
(951) 652-2533
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY: 6CENSUS: 4DATE:
07/10/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Deje Smith, Co-AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs), Stephanie Martinez and Valerie Flores, made an unannounced visit to the facility for the purpose of continuing a required annual inspection. The LPAs were greeted and allowed to enter the facility to conduct the inspection. On today’s visit the LPAs met with Co-Administrator, Deje Smith Wallace; she was notified of the purpose for the visit.

FOOD SERVICE: There was a variety of food which appeared to be selected and stored in a safe and healthful manner. Food supply of nonperishable and perishable foods was sufficient.

RECORD REVIEW: Staff files had required training; including, but not limited to, first aid training and emergency and disaster training. According to Co-Administrator, Wallace, there are no clients in care with a restricted or prohibited health condition. Individual Program Plans (IPP) and Medical Assessments (Physician's Report) were on file for each client in care. During the record review, LPAs observed no results of a TB Test and no ambulatory status for C3. The physician's report for C1 was incomplete; the report was missing the client's diagnoses. A citation will be issued. Co-Administrator Wallace has an active Administrator's certificate, which expires on 05/17/2025. An earthquake drill was completed on 05/09/2024 and a fire drill was completed on 05/03/2024.

MEDICATION: Medications were reviewed for clients in care. Medications were observed to be safe, locked, and inaccessible to clients in care. Centrally Stored Medication Records were observed on file.

This report was reviewed with Co-Administrator Wallace and a copy was provided, along with the LIC 811 and instructions on appeal rights.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 07/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/10/2024
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 2
Document Has Been Signed on 07/10/2024 12:08 PM - It Cannot Be Edited


Created By: Stephanie Martinez On 07/10/2024 at 11:57 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: ROSS HOUSE, THE
FACILITY NUMBER: 336423747

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(c)
Client Medical Assessment: The medical assessment shall include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that the medical assessment for C3 did not include the results of a TB examination or the client's ambulatory status. C1's medical assessment did not include the client's diagnoses. This poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 07/24/2024
Plan of Correction
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Co-Administrator stated follow up will be conducted for the clients medical assessments and proof of correction will be submitted to the Department.
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:Rikesha Stamps
LICENSING EVALUATOR NAME:Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2024


LIC809 (FAS) - (06/04)
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