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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336427444
Report Date: 07/10/2023
Date Signed: 07/10/2023 05:30:07 PM


Document Has Been Signed on 07/10/2023 05:30 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:ABC1 LLCFACILITY NUMBER:
336427444
ADMINISTRATOR:AMY GASAWAYFACILITY TYPE:
735
ADDRESS:24815 MOONSHADOW DRIVETELEPHONE:
(951) 442-5952
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY:6CENSUS: 4DATE:
07/10/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Pamela Lyles, StaffTIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to address an alleged violation reported during the investigation of complaint #18-AS-20230613160726.

During the investigation it was reported by a witness that Administrator, Ester Prothro, on June 13, 2023 called Client One (C1) a liar and said the client was lying about an incident relating to the complaint. Prothro was interviewed and reported to have called C1 a liar. C1 was interviewed and stated no one called them a liar or said they were lying. C1 did however report the Administrator did yell at them on June 13, 2023. This posed a threat to the personal rights of the client in care. Therefore, a citation will be issued.

An exit interview was conducted; this report was reviewed with the Administrator over the phone and a copy was provided.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 782-4807
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 07/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2023
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 2


Document Has Been Signed on 07/10/2023 05:30 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: ABC1 LLC
FACILITY NUMBER: 336427444

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/14/2023
Section Cited
CCR
80072(a)(1)

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PERSONAL RIGHTS: (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. This requirement was not met as evidenced by: Based on interview
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The Administrator stated she would conduct an in-service training relating to personal rights and submit proof to the Department by POC date.
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the Licensee did not ensure C1 was accorded dignity in their relationship with the Administrator. C1 reported the Administrator yelled at them on June 13, 2023.
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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: Jazmond D HarrisTELEPHONE: (951) 782-4807
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 07/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2