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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360909246
Report Date: 07/17/2023
Date Signed: 07/17/2023 03:18:48 PM

Document Has Been Signed on 07/17/2023 03:18 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:PADUA VILLAGE, INC.FACILITY NUMBER:
360909246
ADMINISTRATOR:SHAWN F. BARRACKSFACILITY TYPE:
735
ADDRESS:11981 MIDWAY RD.TELEPHONE:
(760) 248-6245
CITY:LUCERNE VALLEYSTATE: CAZIP CODE:
92356
CAPACITY: 26CENSUS: 19DATE:
07/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Shawn Barracks-AdministratorTIME COMPLETED:
03:25 PM
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On 07/17/23, Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with Administrator, Shawn Barracks, introduced self and stated the purpose of the visit. LPA was informed that there is currently 19 clients in the facility.

The facility has 14 client bedrooms, 8 bathrooms, 2 offices, kitchen, dining area, 4 activity rooms, medication room, laundry room, storage room, and fishing pond. LPA completed a walk through of the facility, review of records and medication audit.

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 between 76-80 degrees fahrenheit in all rooms. LPA inspected the clients bedrooms; all rooms are equipped with required furniture such as: mattresses, night stands, chairs, storage space, and sufficient lighting. LPA inspected clients bathrooms; bathrooms were clean and appliances were functional. An adequate supply of linens and blankets stored in a cabinet inside the laundry room. Water temperature in kitchen faucet tested at 114.7 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, fire extinguisher, first aid kit, and emergency kits. Posters such as; the personal rights, disaster plan and CCL complaint poster were posted in a common area. Cleaning supplies, toxins, and sharps were left unlocked and accessible to clients. Deficiency issued. Medication was kept secured in cabinets inside the locked medication room made inaccessible to clients. There was a designated storage space for clients/staff files inside a filing cabinet in the office. The facility has a working telephone line.

Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Dishes, cups, and utensils were stored properly.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 07/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/17/2023
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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Document Has Been Signed on 07/17/2023 03:18 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 07/17/2023 at 02:26 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: PADUA VILLAGE, INC.
FACILITY NUMBER: 360909246

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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
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Based on observation and interview, the Administrator did not comply with the section cited above in having knives and chemicals accessible to clients which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2023
Plan of Correction
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Administrator immediately locked the knives and chemicals. Administrator stated that he will conduct an all staff training going over regulation 80087(g) and submit proof to LPA via email by POC 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, interview and record review, the Administrator did not comply with the section cited above in administering medication to the client per physician's directions which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2023
Plan of Correction
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Administrator stated that he will provide a refresh training to staff and log random medication audits. Administrator will submit proof to LPA via email by POC 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:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2023


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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: PADUA VILLAGE, INC.
FACILITY NUMBER: 360909246
VISIT DATE: 07/17/2023
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Yards/Outside: One shaded patio, one storage room and one catch and release fishing pond meeting regulations. 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 4 client files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed Administrator's file and 3 staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. Medications were audited at random. LPA observed 2 different medications on 2 different dates signed off on the MARS log without being provided to the client. LPA also observed an expired PRN. Deficiency issued. The facility last conducted a fire drill on June 14, 2023.

Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, and appeal rights were discussed and copies were provided to the Administrator, Shawn Barracks.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023
LIC809 (FAS) - (06/04)
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