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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336424485
Report Date: 05/08/2024
Date Signed: 05/08/2024 04:08:40 PM

Document Has Been Signed on 05/08/2024 04:08 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:MORENO VALLEY GUEST HOME IIFACILITY NUMBER:
336424485
ADMINISTRATOR/
DIRECTOR:		NOYA JACKSONFACILITY TYPE:
735
ADDRESS:15370 LAS ROSAS AVENUETELEPHONE:
(951) 485-8311
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92551
CAPACITY: 6CENSUS: 4DATE:
05/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:40 PM
MET WITH:Administrator Michael CurryTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit. LPA was granted entry and met with caregiver Raul Villanueva, who was informed of the purpose of the visit. Administrator Michael Curry arrived shortly after LPA's arrival. At the time of the visit there was two (2) staff and four (4) clients present. The clients served are developmentally disabled adults between the ages of 18-59. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following:

Physical plant, floors, windows, and doors were observed to be clean and fixtures and furniture were in good repair and were present. The backyard area was observed to have debris which could be potentially hazardous for clients in care. A deficiency 80087(c) will be issued along with a plan of correction. The facility's backyard did not contain a shaded seated area for clients in care. Deficiency 85087.2(b) will be issued along with a plan of correction. The sharp and dangerous objects were observed to be locked and inaccessible to clients located under the kitchen sink. The smoke detector and carbon monoxide was operational, and the hot water temperature was recorded at 108 degrees which met department requirements. LPA observed PPE equipment, hand washing signs, and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements.



LPA observed facility kitchen had the ability to prepare food in clean environment. LPA observed one of four pilots on the stove was not operable. Deficiency 80087(a) will be will be issued along with a plan of correction. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.

LPA reviewed two out of three staff files that contained personal records, criminal record clearance, health screening, and updated training. Staff One (S1) did not have their file available for records review. Deficiency 80066(e) will be issued along with a plan of correction.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: MORENO VALLEY GUEST HOME II
FACILITY NUMBER: 336424485
VISIT DATE: 05/08/2024
NARRATIVE
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Client files were reviewed and possessed all required paperwork including Admissions Agreement, Annual Physician's Report, and current Individual Program Plan (IPP). LPA inspected the P&I for three clients and found the facility did not have the three out of three clients P&I funds available for review or individual bank statement of the client's deposits during the time of the visit. Deficiency 80026(h)(2) will be issued along with a plan of correction.

All client medication was centrally stored and locked in a cabinet located near the kitchen. LPA reviewed medications for two clients and found all medication listed on the Medication Administration Record (MAR) and all required labeling and signatures were found to be in place.

LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing the facility's last fire and earthquake drills was conducted on 03/18/2024, which met the department requirements. LPA observed emergency supplies and first aid kit with all required items. The facility contains multiple charged fired extinguishers located in the facility. The facility does not contain any bodies of water on the property. There are no firearms or ammunition stored at the facility.

An exit interview was conducted where a copy of this report, LIC809-D, LIC 811- confidential names list, and appeal rights was provided to Administrator Curry.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2024
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Document Has Been Signed on 05/08/2024 04:08 PM - It Cannot Be Edited


Created By: Sara Martinez On 05/08/2024 at 03:20 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: 05/08/2024

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 of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in not ensuring the facility was clear and hazard free of two (2) objects of debris in the back yard that poses a potential health, safety, or personal rights risk to clients in care.
POC Due Date: 05/17/2024
Plan of Correction
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Licensee agreed to have the debris removed from the back yard and ensure the facility will be clear of hazardous debris. A photo of the backyard will be sent to LPA when the debris is removed by the plan of correction date 05/17/2024.
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
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Based on observation and interview, the licensee did not comply with the section cited above by ensuring the facility provided a shaded area for outdoor use which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/17/2024
Plan of Correction
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Licensee agreed to obtain shade by either purchasing an umbrella or canopy for clients in care to have a furnished and shaded area for outdoor use. A receipt and photograph of the purchase will be submitted to LPA by the plan of correction date 07/17/2024.
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:Tricia Danielson
LICENSING EVALUATOR NAME:Sara Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 05/08/2024 04:08 PM - It Cannot Be Edited


Created By: Sara Martinez On 05/08/2024 at 03:31 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: 05/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)

(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
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Based on observation, interview, the licensee did not comply with the section cited above in having one (1) pilot on the stove in good repair and working condition which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2024
Plan of Correction
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Licensee will either fix or replace the stove to ensure the facility has appliances in good repair and working condition for the clients in care. Licensee will submit proof of repair of new stove by the plan of correction date 05/31/2024.
Type B
Section Cited
CCR
80066(e)

(e) All personnel records shall be maintained at the facility site and shall be available to the licensing agency for review.

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 in having one (1) out of three (3) staff files available for review during the time of the unannounced visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2024
Plan of Correction
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Licensee agrees to conduct a review/audit of all staff files and ensure that each employee has a file at the facility available for review. Licensee will submit Staff One (S1) file to LPA as proof of correction by the plan of correction date 05/31/2024.
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:Tricia Danielson
LICENSING EVALUATOR NAME:Sara Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 05/08/2024 04:08 PM - It Cannot Be Edited


Created By: Sara Martinez On 05/08/2024 at 03:37 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: 05/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80026(h)(2)
80026 Safeguards for Cash Resources, Personal Property, and Valuables of Residents (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: (2) Bank records for transactions of cash resources deposited in and drawn from the account specified in (i) below.

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 in having three out of three clients funds or individual bank statements available for review during the visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2024
Plan of Correction
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Licensee will submit a statement acknowledging they have read and understand regulation 80026. Licensee will submit a plan on how they will handle the clients money that is in compliance with Title 22 regulations. Licensee will submit statement and plan to LPA by the plan of correction date 05/31/2024.
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:Tricia Danielson
LICENSING EVALUATOR NAME:Sara Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024


LIC809 (FAS) - (06/04)
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