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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360905189
Report Date: 11/18/2024
Date Signed: 11/18/2024 03:51:51 PM

Document Has Been Signed on 11/18/2024 03:51 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:STEPTER'S FAMILY CARE HOMEFACILITY NUMBER:
360905189
ADMINISTRATOR/
DIRECTOR:		BRIGETTE N. FLOWERSFACILITY TYPE:
735
ADDRESS:1219 E. SHAMROCK AVENUETELEPHONE:
(909) 889-1891
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92410
CAPACITY: 10CENSUS: 7DATE:
11/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Susie Stepter, LicenseeTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Eldin Serrano made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection LPA met with Licensee Susie Stepter and was granted entry to the facility. At the time of the visit there was two (2) staff present, and zero (0) residents, as all residents were at Day Program. The facility is a six (6) bedroom, three (3), bathroom home, with a kitchen/dining area, living room, and detached garage. The facility is an Adult Residential (ARF) level 2 designated home, vendorized by Inland Regional Center. Licensed capacity is (10) current census (7). LPA was accompanied by licensee Susie Stepter, to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperatures in the bathrooms to be at within the appropriate temperatures. The facility is equipped with operating smoke detectors and carbon monoxide alarms and found to be in working order. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Facility does not have the emergency disaster drill available for review. Deficiency will be issued. Infection Control Plan was not available for review. Deficiency will be issued. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. There was a designated storage space for client/staff files. Medications are kept inside lock box inaccessible to clients. The facility had emergency kits, emergency food and water. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2024
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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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: STEPTER'S FAMILY CARE HOME
FACILITY NUMBER: 360905189
VISIT DATE: 11/18/2024
NARRATIVE
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Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care.

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, detached two (2) car garage observed. All outdoor pathways were free of obstructions.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department.

Record Review: LPA reviewed three (3) client files for admission agreements, medical assessments/physician reports, and Individual Program Plan (IPP). LPA observed files reviewed were complete. LPA also reviewed licensee and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test result and observed files were complete.

LPA audited three (3) clients’ medications and were observed that the medication administration record (MAR) is not available because it is with the administrator because the doctor wants to review the MAR but did not have a copy for the facility. Deficiency will be issued. LPA did not audit clients’ Personal and Incidental (P&I).


Based on the observations made during today’s visit, deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report was discussed and provided to Susie Stepter.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 11/18/2024 03:51 PM - It Cannot Be Edited


Created By: Eldin Serrano On 11/18/2024 at 03:13 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: STEPTER'S FAMILY CARE HOME
FACILITY NUMBER: 360905189

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(a)
Infection Control Requirements
(a) A licensee shall ensure that infection control practices are maintained as follows:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, record review, the licensee did not comply with the section cited above by not ensuring having a copy of the Infection Control Plan which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/29/2024
Plan of Correction
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Licensee stated that the facility will submit a copy of the Infection Control Plan by the plan of correction (POC) due date.
Type B
Section Cited
CCR
80075(b)(5)(B)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (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,record review, the licensee did not comply with the section cited above by not ensuring that the medication administration record (MAR) was missing on the clients file due to the administrator having to show it to the physician for review but the facility should have a copy of the MAR to determine accuracy of medication administered which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/29/2024
Plan of Correction
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Licensee will provide copies of MAR for the clients reviewed on 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:Karen Clemons
LICENSING EVALUATOR NAME:Eldin Serrano
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 11/18/2024 03:51 PM - It Cannot Be Edited


Created By: Eldin Serrano On 11/18/2024 at 03:13 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: STEPTER'S FAMILY CARE HOME
FACILITY NUMBER: 360905189

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not ensuring that the facility have the emergency disaster drill available for review which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/29/2024
Plan of Correction
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Licensee stated that the facility will submit the emergency disaster drill on the 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:Karen Clemons
LICENSING EVALUATOR NAME:Eldin Serrano
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2024


LIC809 (FAS) - (06/04)
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