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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360911227
Report Date: 12/12/2024
Date Signed: 12/12/2024 03:59:19 PM

Document Has Been Signed on 12/12/2024 03:59 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:SHADY GLENFACILITY NUMBER:
360911227
ADMINISTRATOR/
DIRECTOR:		MICHAEL BRLETICHFACILITY TYPE:
735
ADDRESS:2571 SHADY GLEN LANETELEPHONE:
(909) 783-8806
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92408
CAPACITY: 5CENSUS: 3DATE:
12/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:35 PM
MET WITH:Administrator-Michael BrletichTIME VISIT/
INSPECTION COMPLETED:
04:10 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Beena Singh and Melody Brown made an unannounced visit to the facility to conduct a required annual inspection. LPAs identified themselves to administrator Michael Brletich.

The facility is currently licensed as an Adult Residential Facility, vendored by the Inland Regional Center. The facility has capacity of five ambulatory clients. Three(3) clients were present at the facility during today's visit.

LPAs Singh and Brown toured the interior and exterior of the facility. The facility has no bodies of water. There is a shaded sitting area in the backyard. LPAs Beena Singh and Melody Brown observed that the side gate was unlocked and free of obstruction. The facility has a working telephone for use.909-783-8806.

The facility fire extinguisherx2 observed charged. Administrator Michael Brletich tested the living room smoke alarm and LPAs Beena Singh and Melody Brown found the unit to be in working order. LPAs Singh and Brown observed other smoke alarms in the facility were interconnect and began chiming afterwards. A locked centralized area for sharps, toxins, cleaning agents, and grooming supplies. Medications and facility files and records are kept secured in a locked office.

Physical plant:
Client Bedrooms and Bathroom: Clients and LPAs Beena Singh and Melody Brown observed bedrooms to have the required bedding and furniture, such as, clean mattresses/linen, sufficient storage space,and lighting. However, LPAs observed no chair in one of the client's room. Technical assistance issued.
The facility has a supply of additional linens and towels. LPAs Beena Singh and Melody Brown observed bathrooms were kept in sanitary conditions and provisions for hygiene items are available.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2024
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: SHADY GLEN
FACILITY NUMBER: 360911227
VISIT DATE: 12/12/2024
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LPA observed facility fence in disrepair with 18 sharp nails. Deficiency will be issued. Also during the tour of the facility LPAs observed one (1) window screen in disrepair. Technical violation issued.

LPA observed no night lights maintained in hallways going to bathrooms. Deficiency will be issued.


Kitchen and Dining Areas: LPAs inspected the kitchen and found dishes, glasses, and utensils in good condition and stored in a safe manner. LPAs inspected food provisions and found at least a 2 day supply of perishable food and 7-day supply of non-perishable food items. LPAs reviewed the weekly facility menu. LPA observed a gallon of fabuloso cleaning solution under the sink and not locked and accessible to clients in care. Deficiency will be issued.

Common (living/activity) areas: LPAs Singh and Brown observed adequate seating and board games in the common areas. LPA observed calendar of activities posted on the refrigerator.



The following records were inspected:
LPA observed there is no surety bond maintained at the faciltiy. Deficiency will be issued.
Client Records: LPAs Singh and Brown inspected all client files and found all to have the required documentation, including but not limited to, admissions agreement, recent Individual Program Plan, and current physician's report.

Staff Records: LPAs Beena Singh and Melody Brown reviewed three staff files and found current CPR/first aid certifications. Administrator’s Michael Brletich certificate is current. LPAs reviewed training and disaster drill logs.

Centralized Medication:-Personal and incidentals(P&I) LPAs Beena Singh and Melody Brown reviewed all client medications. LPAs observed all scheduled medications were administered as prescribed. P&I were audited for two(2) clients and no issues were observed.

Deficiencies were cited during this visit. An exit interview was conducted with Administrator Brletich and a copy of this report , LIC 809,LIC809D,LIC9102 and appeal rights were discussed and provided.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 12/12/2024 03:59 PM - It Cannot Be Edited


Created By: Beena Singh On 12/12/2024 at 03:12 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: SHADY GLEN
FACILITY NUMBER: 360911227

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interviews the licensee did not comply with the section cited above by not ensuring that the facility fence is not in disrepair and without 18 sharp nails which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/13/2024
Plan of Correction
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Licensee removed the observed 18 sharp nails in the facility fence during the visit. Also Licensee stated to repair the facility fence and submit proof to LPA Singh by the plan of correction(POC) due date.
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
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Based on observation and interview, the licensee did not comply with the section cited above by not ensuring that the gallon of fabuloso cleaning solution observed under the sink and was locked and not accessible to clients in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/13/2024
Plan of Correction
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Licensee stated to train all staff on CCR 80087(g) and submit proof of all staff training log to LPA Beena Singh by the 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:Efren Malagon
LICENSING EVALUATOR NAME:Beena Singh
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2024


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 12/12/2024 03:59 PM - It Cannot Be Edited


Created By: Beena Singh On 12/12/2024 at 03:12 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: SHADY GLEN
FACILITY NUMBER: 360911227

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80025(b)
Bonding
(b) All licensees, other than governmental entities, who are entrusted to care for and control clients' cash resources shall file or have on file with the licensing agency, a bond issued by a surety company to the State of California as principal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review. the licensee did not comply with the section cited above by not ensuring that the facility has the required surety bond which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/20/2024
Plan of Correction
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Licensee stated to submit an updated copy of facility surety bond to LPA Singh by 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:Efren Malagon
LICENSING EVALUATOR NAME:Beena Singh
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2024


LIC809 (FAS) - (06/04)
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