347006146-7-15-2022-23-CR-SLOR-CGCUML-20220715154228

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347006146
Report Date: 07/14/2022
Date Signed: 07/15/2022 03:43:11 PM

Document Has Been Signed on 07/15/2022 03:43 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, 2525 NATOMAS PARK DR., STE 260
SACRAMENTO, CA 95833

FACILITY NAME:	TURNING POINT- AVALON		FACILITY NUMBER:	347006146
ADMINISTRATOR:	ALICIA CARROLL		FACILITY TYPE:	729
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	4	CENSUS:	DATE:	07/14/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Alicia Caroll, Regional Program Director		TIME COMPLETED:	12:15 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	On 7/14/22 at 9:00am, Licensing Program Analyst (LPA) Stephanie Lor and Licensing Program Manager (LPM) Rosa Rodriouez conducted a Pre-Licensing Inspection, Component II and Component III at the above facility. LPA Lor and LPM Rodriguez met with the Regional Program Director and Cheryl Gutierrez. The facility consisted of a formal living room equipped with a set of 3 couches, a formal dining room equipped with a large table with 6 chairs. There is a resting area/second living room area equipped with a TV and board games. The kitchen was equipped with counter space with 4 stools, locked cabinets to store the sharp objects/knives and dish soaps, plates, utensils, cups, silverware, and a large trash can with lid on. 2 office rooms, one room will be used for staff and to lock the files and medication. The second office (the garage) will be utilized by the Administrator. There are 4 bedrooms equipped with a full size beds, closet (curtain will be installed) dresser, night stand, trash can with lid, 2 1/2 bathrooms, one bathroom is for ambulatory clients and the second bathroom is built especially for non-ambulatory clients. Laundry room equipped with a washer/dryer and lock cabinets to store the laundry soap. There is an open back patio, backyard with a basketball court, and a gated section in back for gardening, The front yard was clean and free of hazards. The telephone land line and internet service were in working order. The water temperature was tested and it was between 105 - 120 degrees. There was a little of perishable/non-perishable food available but more will be purchased prior the first placement. During the pre-inspection, LPA Lor and LPM Rodriguez observed the following: 1 first aid kit which was missing the thermometer, and instruction booklet, 2 fire extinguisher located by the main (see 2nd page)

SUPERVISOR'S NAME: Rosa Rodriguez	TELEPHONE: (916) 662-1458
LICENSING EVALUATOR NAME: Stephanie Lor	TELEPHONE: 530-513-4183
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR., STE 260
SACRAMENTO, CA 95833

FACILITY NAME: TURNING POINT- AVALON	FACILITY NUMBER: 347006146
	VISIT DATE: 07/14/2022

NARRATIVE

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entrance, and kitchen area, carbon monoxide and smoke detector were built in throughout the entire house, system was tested and in working condition.

Component II was completed during today's inspection and the following areas of the Program Statement were reviewed with the Regional Program Director: Program Description, Client Service, Emergency/Disaster Plan, and Exit Criteria. No additional modifications are needed for the Program Statement.

Component III was also completed during today's inspection and the following forms were reviewed with the Regional Program Director: LIC198A -Child Abuse Central Index Check for State Licensed Facilities (family child care homes; children’s residential homes and facilities; and adult residential facilities if, through an approved exception or a specialized license, they provide care to a person under age 18), LIC198B - Out-of-State Child Abuse/Neglect Report Request, · LIC 306-Reporting Requirements to Department. of Social Services, LIC 308 - Designation of Facility Responsibility, LIC 500 - Personnel Report, LIC 501 - Personnel Record, LIC 503 - Health Screening Report (including TB Clearance), LIC 508 -Criminal Record Statement, LIC 508D - Out-of-State Disclosure & Criminal Record Statement, LIC 613B - Personal Rights, LIC 624 -Unusual Incident/Injury/Death Report, LIC 627B - Consent for Medical Treatment, LIC 9058 - Applicant/Licensee Rights, LIC 9182 - Criminal Background Clearance Transfer Request, LIC 9188 Criminal Record Exemption Transfer Request, Appendix D - A Guide to Safeguarding Resident/Client Cash Resources, LIC 311B - Records to be Maintained in a Group Home, LIC 311E - Records to be Maintained in a Small Family Home, LIC 313 - Evidence of Program Consultant (Group Homes), · LIC 601 Identification and Emergency Information, LIC 602 - Physician’s Report for Community Care Facilities, LIC 603 - Preplacement Appraisal Information, LIC 622 - Centrally Stored Medication and Destruction Record, LIC 625 - Appraisal/Needs and Services Plan, LIC 9106 - Group Home Program Statement, LIC 9106A - Short-Term Residential Therapeutic Program (STRTP) Statement General Instructions, LIC 9128 - Foster Family Agency Program Statement, Neighborhood Complaint Policy

(see 3rd page)

SUPERVISOR'S NAME: Rosa Rodriguez	TELEPHONE: (916) 662-1458
LICENSING EVALUATOR NAME: Stephanie Lor	TELEPHONE: 530-513-4183
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR., STE 260
SACRAMENTO, CA 95833

FACILITY NAME: TURNING POINT- AVALON	FACILITY NUMBER: 347006146
	VISIT DATE: 07/14/2022

NARRATIVE

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Regional Program Director was instructed to obtain the following items: Thermometer, First Aid Instruction Booklet, and a small refrigerator to utilize if medication needs to be stored in the refrigerator. LPM Rodriguez informed the Regional Program Director that the facility cannot be licensed until CCL received certification from DDS and certification for the Administrator from the Regional Center.

Exit interview conducted with Regional Program Director and a copy of the report will be emailed by 07/15/2022.

SUPERVISOR'S NAME: Rosa Rodriguez	TELEPHONE: (916) 662-1458
LICENSING EVALUATOR NAME: Stephanie Lor	TELEPHONE: 530-513-4183
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022

LIC809 (FAS) - (06/04)

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