336424327-8-9-2023-18-AS-JROO-CUJULC-20230809154030

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336424327
Report Date: 08/09/2023
Date Signed: 08/09/2023 03:40:41 PM

Document Has Been Signed on 08/09/2023 03:40 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	WALKER RANCH RESIDENTIAL		FACILITY NUMBER:	336424327
ADMINISTRATOR:	WALKER, DANA		FACILITY TYPE:	735
ADDRESS:	15575 GORRION COURT		TELEPHONE:	(951) 924-8837
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92551
CAPACITY: 4		CENSUS: 3	DATE:	08/09/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:22 PM
MET WITH:	Licensee Dana Walker		TIME COMPLETED:	03:45 PM

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On 8/9/2023, Licensing Program Analyst (LPA) Janette Romero arrived unannounced at the facility to conduct an annual required visit. LPA was greeted and granted entry by Caregiver Bernadita Acuna who was informed of the purpose of visit. Licensee Dana Walker arrived during the visit. The facility is approved for 4 ambulatory clients. During the visit, there was three (3) clients and (2) staff present.

LPA toured the facility’s interior and exterior and observed the following:

Kitchen: LPA observed kitchen area to be clean and facility had a 7-day supply of non-perishable food items. LPA observed the facility did not have a 2-day supply of perishable food items. Licensee Walker stated that facility staff provide her with a grocery shopping list on Sundays. Licensee Walker stated that she goes grocery shopping on Tuesdays or Wednesdays on a weekly basis but Licensee Walker did not have time this past Tuesday or Wednesday (8/7/2023, 8/8/2023) to go to the grocery store. LPA also observed several expired food items stored in the refrigerator and pantry. Deficiencies cited.

Dining and Living room: LPA toured the dining and living room area. LPA observed area to be clean and furniture in good condition. LPA observed several board games and activities available for client use.

Records: Staff present have a criminal record clearance on file and are associated to the facility.

Continued on LIC809-C..

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023

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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: WALKER RANCH RESIDENTIAL	FACILITY NUMBER: 336424327
	VISIT DATE: 08/09/2023

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Hallway: LPA observed hallway to be clean with no pathway obstruction. Facility has a fire alarm system and charged fire extinguisher. Carbon monoxide detector was tested and functioning properly. Smoke detector was not tested due to one of the client's hypersensitivity.

Centrally Stored Medications: LPA observed a first aid kit with required components. Medications were secured in a hallway closet. LPA reviewed physical medications for Client #1 (C1) and Client #2 (C2) as well as Medication Administration Record, no discrepancies discovered.

Bedrooms: Resident bedrooms were each furnished with a bed, chair, closet, clothing storage and lighting.

Bathrooms: Bathrooms have a working toilet, wash basin and had non-slip mats in the showers. The facility has clean towels, blankets, and linen, available in different colors for the clients in care. LPA observed the facility did not have wipes/toilet paper readily available in the bathroom shared by C1 and C2. Caregiver Acuna stated C1 has a behavior where C1 attempts to flush a lot of toilet paper down the toilet, causing the toilet to clog. Caregiver Acuna stated that as a result, facility staff provide wipes for C1; however, during tour of the bathroom, LPA did not observe wipes readily available for C1. Licensee Walker stated that C1 pads C1's hands with the toilet paper and makes a big ball of toilet paper and throws it in the trash, and does not attempt to clog the toilet. Caregiver Acuna stated that C2 stores toilet paper rolls in C2's room and travels to the restroom with the toilet paper on an as needed basis.

Yard/Outside Area: All outdoor pathways were free of obstructions. No bodies of water were observed. There were no firearms or ammunition observed at the facility, and LPA was informed the facility will not store firearms or ammunition on the premises.

A copy of this report was discussed and provided to Licensee Walker along with LIC809-D and Appeals Rights.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/09/2023 03:40 PM - It Cannot Be Edited

Created By: Janette Romero On 08/09/2023 at 03:13 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
RIVERSIDE, CA 92507

FACILITY NAME: WALKER RANCH RESIDENTIAL	FACILITY NUMBER: 336424327
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85088(c)(5)

Fixtures, Furniture, Equipment, and Supplies

(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (5) Feminine napkins, nonmedicated soap, toilet paper, toothbrush, toothpaste, and comb. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in due to LPA observing there was no toilet paper/wipes available in client restroom which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/21/2023
	Plan of Correction
1 2 3 4	Licensee agreed to provide staff training regarding providing toilet paper/wipes readily available for clients in care. Proof of correction to be submitted to CCLD by close of business of POC due date.

Type B

Section Cited

CCR

85076(d)(1)

Food Service

(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above by not maintaining a 2-day supply of perishable foods on the premises, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/21/2023
	Plan of Correction
1 2 3 4	Licensee agreed to purchase 2-day supply of perishable food items for clients in care and provide proof of purchase to CCLD by close of business 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:

Joel Esquivel

LICENSING EVALUATOR NAME:

Janette Romero

LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 08/09/2023 03:40 PM - It Cannot Be Edited

Created By: Janette Romero On 08/09/2023 at 03:26 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
RIVERSIDE, CA 92507

FACILITY NAME: WALKER RANCH RESIDENTIAL	FACILITY NUMBER: 336424327
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80076(a)(1)

80076 Food Services (a) In facilities providing meals to clients, the following shall apply: (1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. Each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan - Daily Food Guide for the age group served. All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above due to LPA observing several expired food items, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/21/2023
	Plan of Correction
1 2 3 4	Licensee agreed to dispose of expired food items and provide proof to CCLD by close of business on POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Joel Esquivel

LICENSING EVALUATOR NAME:

Janette Romero

LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023

LIC809 (FAS) - (06/04)

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