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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426105
Report Date: 09/04/2024
Date Signed: 09/05/2024 11:28:21 AM

Document Has Been Signed on 09/05/2024 11:28 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:MEMBERS CLUB WINCHESTERFACILITY NUMBER:
336426105
ADMINISTRATOR/
DIRECTOR:		STIEN BAWENGANFACILITY TYPE:
735
ADDRESS:34827 VINEYARD GREEN CT.TELEPHONE:
(951) 926-7920
CITY:WINCHESTERSTATE: CAZIP CODE:
92596
CAPACITY: 4CENSUS: DATE:
09/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:50 PM
MET WITH:Licensee/Administrator Stien Bawengan TIME VISIT/
INSPECTION COMPLETED:
03:50 PM
NARRATIVE
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On 09/04/2024 at 12:50 PM, Licensing Program Analysts (LPAs) Raquel Hernandez and Melody Brown conducted an unannounced visit to the facility to conduct the required comprehensive annual inspection to the facility. LPAs Hernandez and Brown were greeted by Licensee/Administrator Stien Bawengan and gained access at the home. LPAs Hernandez and Brown explained the purpose of the visit to Licensee/Administrator Stien Bawengan.The facility has five (5) bedrooms, four (4) bathrooms, kitchen, dining room, living room, attached garage, and backyard. The facility is vendorized by Inland Regional Center (IRC). LPAs Hernandez and Brown 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 Hernandez and Brown observed four (4) clients during the visit. There are no obstructions to indoor passageways. However, LPAs Hernandez and Brown observed empty boxes, two old aquariums, luggage, electric fans, and chairs blocking the outdoor passageway. Deficiency will be issued. The facility is maintained at a comfortable temperature of 71 degrees Fahrenheit. LPAs Hernandez and Brown inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, chairs, and sufficient lighting. LPAs Hernandez and Brown inspected client bathrooms; bathrooms were clean, and appliances were found functional. Water temperatures tested at 100 degrees Fahrenheit. Deficiency will be issued. The facility is equipped with operational combined smoke detectors and carbon monoxide detectors, charged fire extinguishers, and first aid kit with first aid book.


Posters such as the personal rights, Ombudsman poster, and emergency disaster plan were posted in a common area. The CCLD complaint poster was posted in common area during the visit. LPAs Hernandez and Brown observed no night lights at the hallway leading to clients' shared bathrooms. Deficiency will be issued. The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility.
*** Continuation in LIC809C ***
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE: DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2024
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 4
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: MEMBERS CLUB WINCHESTER
FACILITY NUMBER: 336426105
VISIT DATE: 09/04/2024
NARRATIVE
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Yards/Outside: One shaded patio, one (1) side gate with self-latching handle on the left side of the house that leads into the backyard, attached two (2) car garage observed.

Food Service: LPAs Hernandez and Brown 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 Hernandez and Brown reviewed two (2) client files for admission agreements, medical assessments/physician reports, and Individual Program Plan (IPP). LPAs Hernandez and Brown observed files reviewed were complete. LPAs Hernandez and Brown also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test result. LPAs Hernandez and Brown observed files reviewed were complete. LPAs Hernandez and Brown audited two (2) clients’ medications. During medication audit LPAs observed two medications from Client #3 (C3) were missing. Deficiency will be issued. LPA’s Hernandez and Brown audited two (2) clients’ 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 Licensee/Administrator Stien Bawengan.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/05/2024 11:28 AM - It Cannot Be Edited


Created By: Raquel Hernandez On 09/04/2024 at 02:55 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: MEMBERS CLUB WINCHESTER
FACILITY NUMBER: 336426105

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(c)
80087 Buildings and Grounds (c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that outdoor passageway was free of obstruction, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/16/2024
Plan of Correction
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Licensee stated to send proof of outdoor passgeway free of obstruction to LPA Hernandez by Plan of Correction (POC) due date.
Type B
Section Cited
CCR
80088(e)(1)
80088 (e) Fixtures, Furniture, Equipment, and Supplies (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delievered to plumbing fixtures used by clients to attain hot water temeperature 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
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Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that the water temperature in the client's bathroom were maintained to not less than 105 and not more than 120 degrees F, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/16/2024
Plan of Correction
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Licensee stated to submit proof of hot water temperature reaching no more than 120 degrees F to LPA Hernandez by POC due date.
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:Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 09/05/2024 11:28 AM - It Cannot Be Edited


Created By: Raquel Hernandez On 09/04/2024 at 03:08 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: MEMBERS CLUB WINCHESTER
FACILITY NUMBER: 336426105

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(5)(B)

80075(b)(5) Health-Related Services (B) Once ordered by the physician the medication is given according to the physician's directions.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that Client #3 (C3) two medications were given according to C3's physicians directions as evidence of two medications were missing during medication audit, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/05/2024
Plan of Correction
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Licensee stated to submit proof of medication training to LPA Hernandez by Plan of Correction (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:Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2024


LIC809 (FAS) - (06/04)
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