<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336424485
Report Date: 05/16/2023
Date Signed: 05/16/2023 12:28:05 PM

Document Has Been Signed on 05/16/2023 12:28 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:MORENO VALLEY GUEST HOME IIFACILITY NUMBER:
336424485
ADMINISTRATOR:NOYA JACKSONFACILITY TYPE:
735
ADDRESS:15370 LAS ROSAS AVENUETELEPHONE:
(951) 242-1316
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92551
CAPACITY: 6CENSUS: 3DATE:
05/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Michael Curry, AdministratorTIME COMPLETED:
12:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to conduct an annual inspection on May 15, 2023. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction and visit purpose. Upon arrival LPA learned that three (3) clients reside at this facility and there are currently one (1) caregiver present. There is no Infection Control Plan on file. Administrator arrived during the inspection.

LPA conducted a tour of the exterior and interior of the facility. The inspection will need to be concluded at another time due to language barrier with Caregiver and Administrator designee in obtaining documents for LPA to complete the inspection process. The following domain was completed: Infection Control. No immediate health and safety risks to residents in care observed.

Client Records-Incident Reports/Clients Rights-Information/Dental- LPA began review of client records. Three (3) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification.

Personnel Records/Training/and Staffing- LPAs began review of employee records- Two (2) records were reviewed. LPA reviewed employee records for first aid certification-no current copies of CPR, criminal record clearance or an exemption, health screening-missing and TB test results, employee rights, training verification-missing, and current administrator certification; expiration date 2/25/2021.



Food Service- Food prep areas are clean and organized. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a locked location for chemicals and sharps in the kitchen. Sharps observed stored with cleaning products in locked cabinet, Administrator immediately relocated sharps. (Continued on LIC809C)
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE: DATE: 05/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2023
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 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MORENO VALLEY GUEST HOME II
FACILITY NUMBER: 336424485
VISIT DATE: 05/16/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
(Continuation from LIC809)

Based on the information received during this visit today in the areas reviewed, seven (7) deficiencies are being cited, civil penalties assessed per Title 22, Division 6 of The California Code of Regulations.

This LIC 809, LIC 809-C, LIC 809-D, LIC421FC and Appeal Rights report was reviewed with the facility representative and a copy will be emailed and a request of confirmation receipt will be requested.

Licensing Program Analyst (LPA) Yolanda Delgado arrived May 16, 2023 unannounced to complete an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction and visit purpose. Upon arrival LPA learned that three (3) clients are away and there are currently one (1) caregiver present.

Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. LPA observed the facility to be clean and some repair. The home is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured 105.0 degrees F. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals. All outdoor and indoor passageways are are obstructed with some debris. Emergency lighting is available. There is a telephone working at this location. The LIC 610, emergency disaster plan is maintained. There are no firearms at this home. This home does not have a pool.

Medications- are centrally stored. There is a locked cabinet allocated for medication storage. Centrally stored medication and destruction logs are maintained. Medications reviewed appear to have been dispensed accurately.

P&I- was unable to be reviewed as no current ledgers available to review.




(Continued on LIC809C)
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023
LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 05/16/2023 12:28 PM - It Cannot Be Edited


Created By: Yolanda Delgado On 05/15/2023 at 04:57 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: MORENO VALLEY GUEST HOME II
FACILITY NUMBER: 336424485

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(2)
Criminal Record Clearance: (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility. (2) Request a transfer of a criminal record clearance as specified in Section 80019(f) or

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in one (1) staff member (Administrator), which poses an immediate health, safety or personal rights risk to persons in care. LPA Delgado Delgado observed that Administrator Michael Curry has approved background clearance, but has not had the clearance transferred to the facility. This is a repeat violation within 12 months.
POC Due Date: 05/16/2023
Plan of Correction
1
2
3
4
Licensee agrees to have the staff member's background clearance transferred to the facility by POC Due date. This may be done by online through Guardian. Licensee will self-certify to LPA once completed.
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:Jazmond D Harris
LICENSING EVALUATOR NAME:Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2023


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 05/16/2023 12:28 PM - It Cannot Be Edited


Created By: Yolanda Delgado On 05/15/2023 at 05:13 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: MORENO VALLEY GUEST HOME II
FACILITY NUMBER: 336424485

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85087.2(b)
Outdoor Activity Space: (b) The outdoor activity area shall provide a shaded area, and shall be comfortable, and furnished for outdoor use.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA Delgado's observation and interview, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care. LPA did not observed shade for the patio and chairs.
POC Due Date: 08/01/2023
Plan of Correction
1
2
3
4
Licensee will obtain shade for outdoor use and submit a photograph to LPA by POC due date.
Type B
Section Cited
CCR
80087(a)
Building and Grounds: (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA Delgado's observation and interview, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed one (1) pilot is not working on the black stove and the light brown flooring in the hallway that leads to bathroom and client rooms is not surfaced evenly for wheelchair resident.
POC Due Date: 08/01/2023
Plan of Correction
1
2
3
4
Licensee will replace the flooring and will clean the stove and possibly replace the stove and submit photographs 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.
SUPERVISOR'S NAME:Jazmond D Harris
LICENSING EVALUATOR NAME:Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2023


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 05/16/2023 12:28 PM - It Cannot Be Edited


Created By: Yolanda Delgado On 05/15/2023 at 05:30 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: MORENO VALLEY GUEST HOME II
FACILITY NUMBER: 336424485

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(c)
Building and Grounds: (c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas o potential hazard shall be kept free of obstruction,

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA Delgado's observation and interview, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed debris on the North side of the backyard and in the back yard that poses a hazard.
POC Due Date: 08/01/2023
Plan of Correction
1
2
3
4
Licensee will clean and remove debris; submit photographs to LPA by POC Due date.
Type B
Section Cited
CCR
85064(b)
Administrator Qualifications and Duties: (b) All adult residential facilities shall have a qualified and currently certified administrator.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care. LPA did not locate a current valid administrator certificate
POC Due Date: 08/01/2023
Plan of Correction
1
2
3
4
Licensee will complete CEU's to obtain certificate, fees have been paid already and will submit copy 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.
SUPERVISOR'S NAME:Jazmond D Harris
LICENSING EVALUATOR NAME:Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2023


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 05/16/2023 12:28 PM - It Cannot Be Edited


Created By: Yolanda Delgado On 05/15/2023 at 05:42 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: MORENO VALLEY GUEST HOME II
FACILITY NUMBER: 336424485

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(e)(2)
Fixtures, Furniture, Equipment, and Supplies: (2) Night lights shall be maintained in hallways and passages to nonprivate bathrooms.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA Delgado observations and interview, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care. LPA did not observe a night light in hallway.
POC Due Date: 08/01/2023
Plan of Correction
1
2
3
4
Licensee will obtain night light and send photograph to LPA by POC due date.
Type B
Section Cited
CCR
80075(f)
Health-Related Services: (f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limitied to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care. LPA did not observe the current valid copies of CPR cards for two (2) staff.
POC Due Date: 08/01/2023
Plan of Correction
1
2
3
4
Licensee will obtain all copies for all staff that have valid CPR training, place in staff files and submit copies 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.
SUPERVISOR'S NAME:Jazmond D Harris
LICENSING EVALUATOR NAME:Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2023


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 05/16/2023 12:28 PM - It Cannot Be Edited


Created By: Yolanda Delgado On 05/16/2023 at 12:02 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: MORENO VALLEY GUEST HOME II
FACILITY NUMBER: 336424485

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022. 

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care. There was no Infection Control on file
POC Due Date: 05/18/2023
Plan of Correction
1
2
3
4
Administrator will complete and fax in the Infection Control Plan to LPA by POC due date.
Type B
Section Cited
CCR
80026(h)
Safeguards for Cash Resources, Personal Property, and Valuables of Resident: (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:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care. LPA could not review P & I ledgers for C1 through C3 as the documents were not available to review. Administrator has in posession away from the facility.
POC Due Date: 05/18/2023
Plan of Correction
1
2
3
4
Administrator will ensure clients ledgers are available at any time when requested to review. Administrator will submit photogaph's of ledgers and current balance of funds 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.
SUPERVISOR'S NAME:Jazmond D Harris
LICENSING EVALUATOR NAME:Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2023


LIC809 (FAS) - (06/04)
Page: 7 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MORENO VALLEY GUEST HOME II
FACILITY NUMBER: 336424485
VISIT DATE: 05/16/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
(CONTINUED FROM LIC809C)

LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguisher was recharged, 09/6/2022. The facility is conducting emergency disaster/fire drills quarterly; last done on 03/12/2023.

Based on the information received during this visit today in the areas reviewed, two (2) deficiencies are being cited per Title 22, Division 6 of The California Code of Regulations.

This LIC 809, LIC 809D and Appeal Rights report was reviewed with the facility representative and a copy will be emailed and a request of confirmation receipt will be requested.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
LIC809 (FAS) - (06/04)
Page: 8 of 8