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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336424628
Report Date: 10/19/2023
Date Signed: 10/19/2023 12:37:43 PM

Document Has Been Signed on 10/19/2023 12:37 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:ULTIMATE SOLUTIONS CARE FACILITY #2FACILITY NUMBER:
336424628
ADMINISTRATOR:KENNETH LEONARDFACILITY TYPE:
735
ADDRESS:10348 WELLS AVENUETELEPHONE:
(951) 729-5628
CITY:RIVERSIDESTATE: CAZIP CODE:
92505
CAPACITY: 4CENSUS: 3DATE:
10/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Administrator Gloria WilliamsTIME COMPLETED:
12:55 PM
NARRATIVE
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On 10/19/2023, Licensing Program Analyst (LPA) Melody Brown arrived unannounced to conduct the required annual visit to the facility. LPA Brown met with Licensee Kenneth Leonard, introduced self and stated purpose of the visit. Administrator Gloria Williams was contacted and arrived during the visit.

The facility has 4 bedrooms, 2 bathrooms, kitchen, dining room, living room, attached garage. The facility is vendorized by Inland Regional Center (IRC). LPA Brown completed a walk-through of the facility, review of records, and P&I audit.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 75 degrees Fahrenheit. LPA Brown inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, dresser, closet, chairs and sufficient lighting but no reading lamps for bedroom #2 and bedroom #3. LPA observed missing reading lamps in in bedroom #2 and bedroom #3. Deficiency issued. LPA Brown inspected client bathrooms; bathrooms were clean, and appliances were found functional. Water temperatures tested at 111 degrees Fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarm, charged fire extinguisher, and first aid kit with first aid book. Posters such as the personal rights, CCL complaint poster, emergency disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, medications, and other dangerous items were kept in secure cabinets inaccessible to clients. Clients/Staff files and P&I were observed locked and made inaccessible. The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility. Overall, the facility is clean, in good repair, and operates in safe conditions for clients in care.

*** Continuation in LIC809C ***
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2023
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 4
Document Has Been Signed on 10/19/2023 12:37 PM - It Cannot Be Edited


Created By: Melody Brown On 10/19/2023 at 11:45 AM
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
, CA 92507

FACILITY NAME: ULTIMATE SOLUTIONS CARE FACILITY #2
FACILITY NUMBER: 336424628

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and ecord review, the licensee did not comply with the section cited above by not having the required Tuberculosis (TB) Test for Staff #1 (S1) and Staff #2 (S2) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/20/2023
Plan of Correction
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Licensee stated to submit TB Test Result/Appointment for S1 and S2 to LPA Brown by POC due date.
Licensee stated to submit Signed Statement of Understanding on CCR 80066(a)(11) to LPA Brown at POC due date.
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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/19/2023 12:37 PM - It Cannot Be Edited


Created By: Melody Brown On 10/19/2023 at 11:45 AM
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
, CA 92507

FACILITY NAME: ULTIMATE SOLUTIONS CARE FACILITY #2
FACILITY NUMBER: 336424628

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(c)(2)
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. (2) Bedroom furniture including, in addition to (c)(1) above, for each client, a chair, a night stand, and a lamp or lights necessary for reading.

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 not having reading lamp in bedroom #2 and bedroom #3 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/27/2023
Plan of Correction
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Licensee stated to purchase/put reading lamp on bedroom #2, and bedroom #3 and submit proof to LPA Brown by POC due date.
Licensee stated to submit Signed Statement of Understanding on CCR 85088(c)(2).
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
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Based on observation, interview and record review the licensee did not comply with the section cited above by not having S2's Administrator Certificate updated/renewed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2023
Plan of Correction
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Licensee stated to submit proof of S2's Administrator Certificate Renewal Process to LPA Brown at POC due date.
Licensee stated to submit Signed Statement of Understanding on CCR 85064(b).
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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023


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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: ULTIMATE SOLUTIONS CARE FACILITY #2
FACILITY NUMBER: 336424628
VISIT DATE: 10/19/2023
NARRATIVE
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Yards/Outside: A backyard was observed and an attached garage. Outdoor pathways were observed with plywoods for the ongoing fence repair on the right side of the facility.

Food Service: LPA Brown observed two (2) days supply of perishable foods and seven (7) days supply of non-perishables food and snacks. Dishes, cups, and utensils were stored properly.



Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Records Review: LPA Brown reviewed client files for admission agreements, updated physician reports, and needs and services plans. LPA Brown also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings and Tuberculosis (TB) test. LPA Brown observed Staff #1 (S1) and Staff #2 (S2) without the required Tuberculosis (TB) test. LPA Brown informed Administrator Williams that deficiency will be issued as this pose immediate health, safety and personal rights risk to clients in care. Moreover, LPA Brown observed expired Administrator Certificate for S2. Deficiency issued. Furthermore, P& I was audited, and no deficiencies observed.

Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D and Appeal Rights were discussed and copies were provided to Administrator Gloria Williams..

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
LIC809 (FAS) - (06/04)
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