336424322-9-5-2024-18-AS-JARA-D8TTD6-20240905143749

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336424322
Report Date: 09/05/2024
Date Signed: 09/05/2024 02:37:58 PM

Document Has Been Signed on 09/05/2024 02:37 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:	D&D HOME #3		FACILITY NUMBER:	336424322
ADMINISTRATOR/ DIRECTOR:	DOUGLAS P BEATTY III		FACILITY TYPE:	735
ADDRESS:	28769 GOLDEN DAWN DRIVE		TELEPHONE:	(951) 301-8572
CITY:	MENIFEE	STATE: CA	ZIP CODE:	92584
CAPACITY: 6		CENSUS: 4	DATE:	09/05/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:10 PM
MET WITH:	Licensee, Deborah Lee		TIME VISIT/ INSPECTION COMPLETED:	02:40 PM

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Licensing Program Analysts (LPAs) Janira Arreola and Debbie Palacios conducted an unannounced annual required visit. LPA was granted entry and met with Licensee, Deborah Lee who was informed of the purpose of the visit. At the time of the visit there was (3) staff and (4) clients present.

The facility is a two story home with (4) bedrooms and (2) bathrooms downstairs for the clients. No pools or firearms are being kept at the facility.

Infection Control: The LPA observed hygiene supplies, PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements.

Physical Plant: Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to clients. The smoke detector and carbon monoxide was operational, and the hot water temperature 112F.

Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: D&D HOME #3	FACILITY NUMBER: 336424322
	VISIT DATE: 09/05/2024

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Care & Supervision/Administration: Adequate staff are present for the supervision of clients during the visit. LPA also reviewed the staff scheduled showing adequate staff coverage.

Record Review and Resident/Staff Files: LPA reviewed (2) staff files and training. Technical note was documented for (1) staff that had not conducted health screening, but was within the employment window. Two (2) client files were reviewed, (1) resident did not have their IPP in their file. Technical note was documented for this, the Licensee agreed to send this documentation by 9/11/2024.

Health Related Services/ Incidental Medical Services: All client medication was locked in closet. LPA reviewed client medications for clients and found all medication listed on MARS and accounted for.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing the facility's last fire drill 8/26/2024, which met the department requirements. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies in the and first aid kit with all required items.

No deficiencies were cited at the time of the visit. An exit interview was conducted where this report was reviewed and provided.

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024

LIC809 (FAS) - (06/04)

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