336426123-4-24-2023-18-AS-JARA-CR7QYX-20230424123552

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336426123
Report Date: 04/24/2023
Date Signed: 04/24/2023 12:36:10 PM

Document Has Been Signed on 04/24/2023 12:36 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
RIVERSIDE, CA 92507

FACILITY NAME:	SHIRU RESIDENCES LLC		FACILITY NUMBER:	336426123
ADMINISTRATOR:	SMITH, SHIRLEY		FACILITY TYPE:	735
ADDRESS:	9752 VIA MONTARA		TELEPHONE:	(951) 206-4206
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92557
CAPACITY: 2		CENSUS: 2	DATE:	04/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:17 AM
MET WITH:	Administrator, Shirley Smith		TIME COMPLETED:	12:45 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

Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit on 4/24/2023 at 09:17 a.m. LPA was granted entry and met with staff, Sean Smith who was informed of the purpose of the visit. The administrator arrived at the facility after LPA who was also informed of the purpose of the visit. At the time of the visit there was (2) staff and (1) clients present.

The facility is a two story home with (5) bedrooms and (4) bathrooms for clients. The clients served are adults between the ages of 18-59. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted staff and client interviews. LPA observed the following:

Infection Control: The LPA observed the hand washing stations in the facility restrooms. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan and found all required infection control measures.

Physical Plant: LPA observed the client bedrooms. Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. Laundry room was observed to be have a laundry detergent that was left in unlocked laundry room. Cleaning supplies were unlocked in cabinet in laundry room as well. Staff secured the cleaning supplies in front of LPA. LPA also observed (2) unlocked scissors on the kitchen counter. LPA cited this deficiency and created a plan of correction with the facility administrator. The LPA was informed by staff that the laundry washer had needed repair on Friday and was scheduled to me repair tomorrow on Tuesday. LPA was informed by administrator was plan, in case the repairs are delayed to clean resident and facility laundry.

Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.

Care & Supervision/Administration: Adequate staff are present for the supervision of clients. Floor plans, telephone numbers and personal rights were found in the facility. The listed administrator, possesses a current administrator's certificate.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023

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 6

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
RIVERSIDE, CA 92507

FACILITY NAME: SHIRU RESIDENCES LLC	FACILITY NUMBER: 336426123
	VISIT DATE: 04/24/2023

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

Record Review and Resident/Staff Files: LPA reviewed (3) staff files and reviewed the facility's staff schedule. All staff have criminal clearance and updated training along with CPR/First Aid Certification. Two (2) client files were reviewed, and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: All client medication was locked in a medication cabinet. LPA reviewed client medications for (2) clients and found all medication listed on medication administration log. All required labeling was found to be in place, and all medication was accounted for.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan as well as disaster training binder. LPA reviewed documentation showing the facility last fire drill was conducted on October 15, 2022. The facility is past due for a quarterly drill. The licensewill send the report by the end of the business day to the LPA's email. LPA also observed the LIC610D. LPA observed emergency food supply in the facility garage, along with emergency water.

An exit interview was conducted where a copy of this report along with LIC 809-D pages, and appeal rights were provided to Administrator, Shirley Smith.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023

LIC809 (FAS) - (06/04)

Page: 2 of 6

Document Has Been Signed on 04/24/2023 12:36 PM - It Cannot Be Edited

Created By: Janira Arreola On 04/24/2023 at 11:52 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
RIVERSIDE, CA 92507

FACILITY NAME: SHIRU RESIDENCES LLC	FACILITY NUMBER: 336426123
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80087(g)

Building and Grounds

(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above with (2) pairs of scissors and (1) bottle of laundry detergent that were unlocked and accessible to residents. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/25/2023
	Plan of Correction
1 2 3 4	The licensee agree to send the LPA a written plan on how they plan to store the sharp objects and chemicals in the facility to ensure they are inaccessible to the residents at all times. This plan shall be signed by the administrator along with all staff and submitted to the LPA by the 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:

Joel Esquivel

LICENSING EVALUATOR NAME:

Janira Arreola

LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023

LIC809 (FAS) - (06/04)

Page: 3 of 6