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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425532
Report Date: 02/15/2023
Date Signed: 03/16/2023 01:52:13 PM


Document Has Been Signed on 03/16/2023 01:52 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 03/16/2023 11:26 AM

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

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Licensing Program Analysts (LPAs) Janira Arreola and Jacqueline Shaw Ross conducted an unannounced visit to the facility on 02/15/2023 at 9:30 am in order to verify corrections of citations issued as a result of complaint #18-AS-20221122092817 on 01/18/2023. LPAs met with Staff, Mary Anne Harmison and Licensee Brandon Harmison , who were informed of the purpose of the visit. At the time of the visit there were (3) staff and (4) residents present.

The following deficiency were not corrected by the POC due date nor at the time of the visit. Civil Penalties are being assessed and will continue to accrue until correction has been submitted:
Deficiency cited under Title 22 Regulation 87405(d)(5) Administrator - Qualifications and Duties. POC was to no longer do illegal drugs at the facility. Licensee was to provide a written statement stating they would no longer allow illegal drug use at the facility and would submit a drug test as proof. The statement was due by 01/19/23. The drug test was to be completed at a doctor's office to confirm it was completed by Licensee Harmison and was also due 1/19/2023. An extension was requested and granted for the drug test to be completed on 2/10/2023. On today's visit the LPAs spoke with the licensee who stated that they no longer wished to carry out the plan of correction to do a drug test. Civil penalties are being assessed for the dates of 2/11/2023 to 2/15/2023 in the amount of $100 per day for 5 days. Civil penalties will continue to accrue at the rate of $100 a day until the POC is submitted.

An exit interview was conducted where this report along with LIC421FC form was reviewed and provided to staff, Mary Anne Harmison.

*This is an amended report which was delivered and signed by Licensing Program Analyst Tricia Danielson.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2023
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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