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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800105
Report Date: 08/15/2024
Date Signed: 09/09/2024 03:27:35 PM

Document Has Been Signed on 09/09/2024 03:27 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:LAVERNE'S ABUNDANCE OF LOVEFACILITY NUMBER:
361800105
ADMINISTRATOR/
DIRECTOR:		VANA MARIE JUSTICEFACILITY TYPE:
735
ADDRESS:14905 MESA LINDA AVETELEPHONE:
(760) 241-5251
CITY:VICTORVILLESTATE: CAZIP CODE:
92394
CAPACITY: 4CENSUS: 4DATE:
08/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:38 AM
MET WITH:Vana Marie Justice-LicenseeTIME VISIT/
INSPECTION COMPLETED:
01:28 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Michelle Echeverria, Lavette Farlow and Becky Mann arrived unannounced to conduct the required annual visit to the facility. LPAs met with Licensee, Vana Marie Justice, and introduced self and stated purpose of the visit. LPAs were informed that there is 1 client home and 3 in day program.

The facility has 4 bedrooms, 3 bathrooms, living room, kitchen, dining area, family room, laundry room, attached garage, and backyard. The facility is not vendorized by Inland Regional Center. LPAs completed a walk through of facility, review of records, medication and P&I 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 of 77 degrees fahrenheit. LPAs inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting. LPAs observed that there were 2 client chairs missing. Deficiency issued. LPAs inspected client bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 111.6 degrees fahrenheit. LPAs observed that the facility did not have sufficient linen for clients in care. Deficiency issued. The facility is equipped with operational smoke detectors, carbon monoxide alarms and charged fire extinguisher. Posters such as; the personal rights, CCL complaint poster and disaster plans were posted in a common area. LPAs observed that the emergency disaster plan was not reviewed/updated since 7/28/16. Technical violation issued. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients. There was a designated storage space for client/staff files. Medications and first aid kit were observed in secure cabinets and inaccessible to clients. There are no firearms or ammunition in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care.

Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a wide variety of food available for clients. Dishes, cups, and utensils were also stored properly. LPAs observed that the pantry had a lock which is locked at night for clients to not have access per administrator statement. Deficiency issued.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2024
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 6
Document Has Been Signed on 09/09/2024 03:27 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 08/15/2024 at 12:09 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: LAVERNE'S ABUNDANCE OF LOVE
FACILITY NUMBER: 361800105

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(c)(2)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (2) Bedroom furniture including, in addition to (c)(1) above, for each client, a chair, a night stand, and a lamp or lights necessary for reading.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in providing chairs for 2 clients which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2024
Plan of Correction
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Licensee stated that she will purchase chairs for 2 clients and submit proof of pictures and receipt to LPA via email by POC due date.
Type B
Section Cited
CCR
85088(c)(4)(A)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (4) Clean linen in good repair, including lightweight, warm blankets and bedspreads; top and bottom bed sheets; pillow cases; mattress pads; rubber or plastic sheeting, when necessary; and bath towels, hand towels and wash cloths. (A) The quantity of linen provided shall permit changing the linen at least once each week or more often when necessary to ensure that clean linen is in use by clients at all times.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in providing back up linen for all clients which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2024
Plan of Correction
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Licensee stated that she will provide back up linen for all clients and submit proof to LPA via email by 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:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2024


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 09/09/2024 03:27 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 08/15/2024 at 12:09 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: LAVERNE'S ABUNDANCE OF LOVE
FACILITY NUMBER: 361800105

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2024

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 and record review, the licensee did not comply with the section cited above in having a surety bond on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2024
Plan of Correction
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Licensee stated that she will purchase a surety bond and submit proof to LPA via email by POC due date.
Type B
Section Cited
CCR
80066(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in maintaining complete personnel records which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2024
Plan of Correction
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Licensee stated that she will submit a statement of understanding on regulation cited and send proof to LPA via email by 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:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 09/09/2024 03:27 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 08/15/2024 at 12:09 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: LAVERNE'S ABUNDANCE OF LOVE
FACILITY NUMBER: 361800105

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80072(a)
Personal Rights
(a) Except for children's residential facilities, each client shall have personal rights which include, but are not limited to, the following:

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 in restricting the clients access to the pantry by locking it at night which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2024
Plan of Correction
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Licensee stated that she will remove the lock from the pantry and submit proof of picture to LPA via email by POC due date.
Type B
Section Cited
CCR
80068(a)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in having the clients and conservator sign the admission agreement which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2024
Plan of Correction
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Licensee stated that she will submit a statement of understanding on regulation cited and submit proof to LPA via email by 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:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 09/09/2024 03:27 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 08/15/2024 at 12:09 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: LAVERNE'S ABUNDANCE OF LOVE
FACILITY NUMBER: 361800105

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(b)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in making sure that staff were assisting clients with medication which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2024
Plan of Correction
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Licensee stated that she will train staff on regulation cited and submit proof to LPA via email by POC due date.
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 observation, interview and record review, the licensee did not comply with the section cited above in conducting emergency drills quarterly which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2024
Plan of Correction
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Licensee stated that she will conduct emergency drills quarterly and submit proof to LPA via email by 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:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2024


LIC809 (FAS) - (06/04)
Page: 5 of 6
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: LAVERNE'S ABUNDANCE OF LOVE
FACILITY NUMBER: 361800105
VISIT DATE: 08/15/2024
NARRATIVE
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Yards/Outside: LPAs observed one shaded patio, a side gate with self-latching handle on the left side of the house that leads into the backyard. All outdoor pathways were free of obstructions.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. Licensee and sister reside in the home.

Record Review: LPAs reviewed client files for admission agreements, updated physician reports, and needs and services plans. LPAs observed that all client admission agreements have not been acknowledge by the client and designated party. Deficiency issued. LPA also reviewed Licensee and staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPAs observed that the personnel records were incomplete and missing mandatory documents. Deficiency issued. P & I funds were audited and matched with the ledger. Medication was audited and LPAs observed that staff are not assisting clients with medication as instructed. Deficiency issued. LPAs observed that the facility did not perform disaster drills. Deficiency issued. LPAs observed that the surety bond has not been renewed since 7/4/19. Deficiency issued.

Deficiencies and one technical violation were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102TV and appeal rights were discussed and copies were provided to the Licensee, Vana Marie Justice.

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

DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024
LIC809 (FAS) - (06/04)
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