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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425810
Report Date: 12/06/2024
Date Signed: 12/06/2024 09:43:21 AM

Document Has Been Signed on 12/06/2024 09:43 AM - 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:DANIEL HOMEFACILITY NUMBER:
336425810
ADMINISTRATOR/
DIRECTOR:		ADILENE QUINTANILLAFACILITY TYPE:
735
ADDRESS:30839 VIA PAREDTELEPHONE:
(760) 565-7905
CITY:THOUSAND PALMSSTATE: CAZIP CODE:
92276
CAPACITY: 6CENSUS: 4DATE:
12/06/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Abigail FlathTIME VISIT/
INSPECTION COMPLETED:
09:50 AM
NARRATIVE
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This Case management– Deficiencies inspection is being conducted by Licensing Program Analyst (LPA) Abdoulaye Zerbo on 12-06-24 for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 18-AS-20241202123606. LPA met with Abigail Flath and explained purpose of the visit.

During the visit, LPA reviewed record and observed all four(4) clients not having a current IPP on file.

Based on observations, record review and interviews , deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809-D.

An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative, Abigail Flath.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2024
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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Document Has Been Signed on 12/06/2024 09:43 AM - It Cannot Be Edited


Created By: Abdoulaye Zerbo On 12/04/2024 at 03:28 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: DANIEL HOME
FACILITY NUMBER: 336425810

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/03/2025
Section Cited
CCR
85068.2(b)(1)(F)

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(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (F) The written functional capabilities assessment specified in Section 80069.2.
This requirement is not met as evidenced by:
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Licensee will obtain a current IPP and email a copy to LPA by POC due date.
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Based on LPA Zerbo's observation, interview and record review, the licensee did not comply with the section cited above in four(4) of Four(4) did not have a current IPP which poses/posed a potential health, safety or personal rights risk to persons in care.
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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:Rikesha Stamps
LICENSING EVALUATOR NAME:Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2024


LIC809 (FAS) - (06/04)
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