336425055-9-17-2024-56-AS-ESEO-D984Q4-20240917191742

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336425055
Report Date: 09/17/2024
Date Signed: 09/17/2024 07:19:10 PM

Document Has Been Signed on 09/17/2024 07:19 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	MOQUETE FAMILY HOME, THE		FACILITY NUMBER:	336425055
ADMINISTRATOR/ DIRECTOR:	MOQUETE, NANCY		FACILITY TYPE:	735
ADDRESS:	7976 POPPY ST.		TELEPHONE:	(951) 817-2556
CITY:	CORONA	STATE: CA	ZIP CODE:	92881
CAPACITY: 6		CENSUS: 4	DATE:	09/17/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	04:15 PM
MET WITH:	Marcela Hurtado, Administrator		TIME VISIT/ INSPECTION COMPLETED:	07:20 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	On 09/17//2024 at 04:15 PM, Licensing Program Analysts (LPAs) Melody Brown and Eldin Serrano conducted an unannounced visit to the facility to conduct the required comprehensive annual inspection to the facility. LPAs Brown and Serrano were greeted by Administrator Marcela Hurtado and gained access at the home. LPAs Brown and Serrano explained the purpose of the visit to Administrator Marcela Hurtado . The facility has six (6) bedrooms, three (3) bathrooms, kitchen, dining room, living room, attached garage, and backyard. The facility is vendorized by Inland Regional Center (IRC). The facility are licensed for 6 of which can be ambulatory. LPAs Brown and Serrano completed a walkthrough of the facility, review of records, Personal and Incidental (P&I) and medications audit. Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD), LPAs Brown and Serrano observed four (4) clients during the visit. There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 76 degrees Fahrenheit. LPAs Brown and Serrano inspected client bedrooms; they are equipped with required furniture such as: mattresses, storage space, chairs, and sufficient lighting. LPAs Brown and Serrano inspected client bathrooms; bathrooms were clean, and appliances were found functional. Water temperatures tested at 106 degrees Fahrenheit. The facility is equipped with operational combined smoke detectors and carbon monoxide detectors, charged fire extinguishers, and first aid kit with first aid book. In addition, LPAs Brown and Serrano observed non-slip mat on client’s bathroom. Posters such as the personal rights, CCLD complaint poster, and emergency disaster plan were posted in a common area. Client medications were kept in secure cabinets inaccessible to clients. LPAs Brown and Serrano observed night lights at the hallway leading to clients' shared bathrooms. The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility. * Continuation in LIC809C *

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024

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 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MOQUETE FAMILY HOME, THE	FACILITY NUMBER: 336425055
	VISIT DATE: 09/17/2024

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

Yards/Outside: One shaded patio, one (1) side gate with self-latching handle on the right side of the house that leads into the backyard and driveway in front of the house. All outdoor pathways were free of obstructions.

Food Service: LPAs Brown and Serrano observed two (2) day(s) supply of perishable food and seven (7) day(s) 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.

Record Review: LPAs Brown and Serrano reviewed two (2) client files for admission agreements, medical assessments/physician reports, centrally stored medication and Individual Program Plan (IPP). LPAs Brown and Serrano observed files reviewed were complete. LPAs Brown and Serrano also reviewed staff and administrator's file for First Aid/CPR and CPI certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test result. LPAs Brown and Serrano observed Staff #2 (S2) and staff #3 (S3) do not have the required CPR/First Aid certification Deficiency will be issued.

LPAs Brown and Serrano audited two (2) clients’ medications and no issues were observed. LPAs Brown and Serrano audited two (2) client's Personal and Incidental (P&I) and no issues observed.

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

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 09/17/2024 07:19 PM - It Cannot Be Edited

Created By: Eldin Serrano On 09/17/2024 at 06:59 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: MOQUETE FAMILY HOME, THE	FACILITY NUMBER: 336425055
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

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 limited to the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that staff 2 (S2) and staff 3 (S3) complete the required First Aid/CPR certification which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/18/2024
	Plan of Correction
1 2 3 4	LIcensee stated to submit the required First Aid/CPR certification for S2 and S3 to LPA Serrano on the plan of correction (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:

Karen Clemons

LICENSING EVALUATOR NAME:

Eldin Serrano

LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3