336424626-9-19-2023-18-AS-JROO-CVTSAH-20230919134223

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336424626
Report Date: 09/19/2023
Date Signed: 09/19/2023 01:42:28 PM

Document Has Been Signed on 09/19/2023 01:42 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:	PLEASANT GROVE RESIDENTIAL		FACILITY NUMBER:	336424626
ADMINISTRATOR:	KEITH WALKER		FACILITY TYPE:	735
ADDRESS:	25183 TODD DRIVE		TELEPHONE:	(951) 924-2300
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92553
CAPACITY: 4		CENSUS: 4	DATE:	09/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	House Manager, Desean Walker		TIME COMPLETED:	01:45 PM

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On 9/19/2023, Licensing Program Analyst (LPA) Janette Romero arrived unannounced at the facility to conduct an annual required visit. LPA was greeted and granted entry by House Manager, Desean Walker who was informed of the ,purpose of visit. During the visit, there was one (1) staff and one (1) client present, and LPA was informed that two (2) clients were at day program and one (1) was out in the community.

The facility is approved to care for four (4) ambulatory clients and serves adults ages 18 through 59. LPA toured the facility's interior and exterior with House Manager Walker. The facility is made up of a one-story home with four (4) client bedrooms, one (1) client bathroom, a living room, a staff office, staff bathroom, kitchen, dining room, and garage. During the visit, LPA observed the following:

Kitchen: Kitchen area to be clean and food is stored in a safe and healthful manner. The facility had a 2-day supply of perishable food items and 7-day of non-perishable food items. Knives were secured in a kitchen cabinet.

Dining and Living rooms: LPA toured the dining and living room. LPA observed areas to be clean and furniture in good condition.

Hallway: LPA toured the hallway and observed hallway to be clean with no pathway obstruction. Carbon monoxide and smoke detectors were tested and functioning properly. A fire extinguisher was charged and mounted in the kitchen.

Records: Staff present has a criminal record clearance on file, is associated to the facility and has current CPR/First Aid certification.

Continued on LIC809-C..

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023

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: PLEASANT GROVE RESIDENTIAL	FACILITY NUMBER: 336424626
	VISIT DATE: 09/19/2023

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Continued from LIC809
Centrally Stored Medications: LPA observed a first aid kit with required components. Medications were secured in a file cabinet in the staff room. LPA reviewed physical medications for two (2) clients as well as the Medication Administration Record (MAR) used to log administration of clients’ medications. No discrepancies discovered.

Bedrooms: Client bedrooms were each furnished with a bed, chair, closet, clothing storage and lighting. LPA toured Client #1 and Client #2's bedrooms and noticed that both mattresses appeared to be caving in the middle. LPA assessed that both mattresses did not have good bed springs. Deficiency cited.

Bathrooms: Bathrooms have a working toilet and were equipped with a nonskid mat in the shower. Initially, the hot water temperature in the client bathroom faucet was heating up. House Manager Walker attempted to regulate the hot water in the client's bathroom and then the faucet stopped working. LPA measured the hot water temperature in the staff bathroom and it measured at 151-degrees Fahrenheit. Deficiency cited.

Laundry/Garage: LPA observed the laundry room and garage to be clean. Washing machine and dryer are in good repair. Cleaning solutions and chemicals are secured in the staff office. The facility had four (4) backpacks filled with emergency kits available for clients.

Yard/Outside Area: Covered patio seating is available for clients in care. A wood wall secured the entire backyard. All outdoor pathways were free of obstructions. No bodies of water were observed.

Clients' Cash Resources: LPA reviewed the Record of Client's/Resident's Safeguarded Cash Resources (LIC 405) used to record clients' cash resources. No discrepancies discovered.

During today's visit, LPA observed one deficiency faulting the facility. An exit interview was conducted, and a copy of this report was reviewed and provided to House Manager Walker along with an LIC809-D, Confidential Names List (LIC811), and Appeal Rights.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/19/2023 01:42 PM - It Cannot Be Edited

Created By: Janette Romero On 09/19/2023 at 01:06 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: PLEASANT GROVE RESIDENTIAL	FACILITY NUMBER: 336424626
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85088(c)(1)

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. (1) An individual bed, except that couples shall be allowed to share one double or larger sized bed, maintained in good repair, and equipped with good bed springs, a clean mattress and pillow(s). 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 assessing that two mattressess used by Client #1 and Client #2 did not have good bed springs, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/19/2023
	Plan of Correction
1 2 3 4	Licensee stated that the facility will replace both mattressess and provide proof of correction to LPA by close of business on 9/20/2023.

Type B

Section Cited

CCR

80088(e)(1)

80088 Furniture, Fixtures, Equipment, and Supplies (e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). 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 the client bathroom not having hot water available, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/19/2023
	Plan of Correction
1 2 3 4	Licensee stated the facility will contact a plumber to repair the clients' bathroom faucet and regulate the hot water temperature in the client and staff bathroom to allow clients to attain a hot water temperature between 105- and 120-degrees F. Proof of correction to be submitted to LPA by COB on 9/29/2023.

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: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

LIC809 (FAS) - (06/04)

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