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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800193
Report Date: 11/21/2024
Date Signed: 11/21/2024 03:00:18 PM

Document Has Been Signed on 11/21/2024 03:00 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:TRUST & GRACE ADULT CARE HOMEFACILITY NUMBER:
361800193
ADMINISTRATOR/
DIRECTOR:		MARTIN, CHERRYFACILITY TYPE:
735
ADDRESS:12295 ANDREA DRIVETELEPHONE:
(760) 488-1602
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 4CENSUS: 4DATE:
11/21/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:39 AM
MET WITH:Dameon Lester-Assistant AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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 Licensing Program Analyst (LPA) Michelle Echeverria arrived at the facility unannounced to conclude the required Annual visit initiated on 11/19/2024. LPA introduced self and stated the purpose of the visit to Assistant Administrator, Dameon Lester.

The facility has 4 bedrooms, 2 bathrooms, a kitchen, dining area, entry/office room, family room, laundry room, attached garage, and backyard. The facility is vendorized by Inland Regional Center. LPA completed a walk through of facility, review of records, 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 75 degrees fahrenheit. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected client bathrooms; bathrooms were clean and appliances were found functional. LPA observed a trail of ants in the clients bedrooms and bathrooms. Deficiency issued. Water temperatures tested at 121.9 degrees fahrenheit. LPA observed the following: a leaking refrigerator, broken kitchen cabinet, holes in the bedrooms walls, bathroom walls, bedroom doors and dirty floors. Deficiency issued. The facility is equipped with operational smoke detectors, carbon monoxide alarms, charged fire extinguisher, first aid kit, emergency kits and emergency food and water. Posters such as; the personal rights, disaster plans, and CCL complaint poster were posted in a common area. LPA observed accessible chemicals, detergents and medications in the kitchen cabinet, laundry room, and clients bedrooms. Deficiency issued. There was a designated storage space for client/staff files. Medications was observed locked and inaccessible to clients. There is no swimming pool, bodies of water, firearms or ammunition in the facility. LPA observed no lighting in entry/office area and restricted lighting in the clients bedrooms. Deficiency issued. LPA observed that the facility did not have deodorants for the clients. Deficiency issued.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2024
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 10
Document Has Been Signed on 11/21/2024 03:00 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 11/21/2024 at 12:47 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: TRUST & GRACE ADULT CARE HOME
FACILITY NUMBER: 361800193

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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, the assistant administrator did not comply with the section cited above in not making the chemicals, detergents and medications in the kitchen cabinet, laundry room, and clients bedrooms accessible which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/21/2024
Plan of Correction
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The assistant administrator made the chemicals, detergents and medications inaccessible. The assistant administrator stated that training will be provided to all staff on the regulation cited and submit proof of attendance sheet to LPA via email by 12/6/24.
Type A
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, interview and record review, the assistant administrator did not comply with the section cited above in maintaining valid records of health screenings, TB tests and trainings in all personnel records which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2024
Plan of Correction
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Assistant administrator stated that he will submit a statement of understanding on the regulation cited to LPA via email by POC due date. Assistant administrator will also review/update/correct all personnel records.
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: 11/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2024


LIC809 (FAS) - (06/04)
Page: 2 of 10
Document Has Been Signed on 11/21/2024 03:00 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 11/21/2024 at 12:47 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: TRUST & GRACE ADULT CARE HOME
FACILITY NUMBER: 361800193

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the assistant administrator did not comply with the section cited above in providing 2 days of perishables and 7 days of nonperishables in the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2024
Plan of Correction
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Assistant Administrator stated that he will purchase 2 days of perishables and 7 days of nonperishables and submit pictures of food and receipts to LPA via text by 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:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2024


LIC809 (FAS) - (06/04)
Page: 3 of 10
Document Has Been Signed on 11/21/2024 03:00 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 11/21/2024 at 12:47 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: TRUST & GRACE ADULT CARE HOME
FACILITY NUMBER: 361800193

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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, the assistant administrator did not comply with the section cited above in correcting the leaking refrigerator, broken kitchen cabinet, holes in the bedrooms walls, bathroom walls, bedroom doors and dirty floors which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2024
Plan of Correction
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Assistant administrator stated that he will repair the leaking refrigerator, broken kitchen cabinet, holes in the bedrooms walls, bathroom walls, bedroom doors and clean the floors in the facility. Assistant administrator will submit pictures as proof of corrections to LPA via email by POC due date.
Type B
Section Cited
CCR
80087(a)(1)
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. (1) The licensee shall take measures to keep the facility free of flies and other insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the assistant administrator did not comply with the section cited above in maintaining the facility free of pest which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2024
Plan of Correction
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Assistant administrator stated that he will hire pest control to address the ants and roaches in the facility. Assistant administrator will submit a copy of the invoice 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: 11/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2024


LIC809 (FAS) - (06/04)
Page: 4 of 10
Document Has Been Signed on 11/21/2024 03:00 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 11/21/2024 at 12:47 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: TRUST & GRACE ADULT CARE HOME
FACILITY NUMBER: 361800193

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(d)
Fixtures, Furniture, Equipment, and Supplies
(d) The licensee shall provide lamps or lights as necessary in all rooms and other areas to ensure the comfort and safety of all persons in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the assistant administrator did not comply with the section cited above in providing sufficient lighting in all rooms of the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2024
Plan of Correction
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Assistant administrator stated that lamps will be purchased for all client bedrooms and entry/office area and will submit picture of lamps and receipts to LPA via email by POC due date.
Type B
Section Cited
CCR
85088(c)
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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the assistant administrator did not comply with the section cited above in maintaining a stock of deodorants which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2024
Plan of Correction
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Assistant administrator stated that he will purchase deodorants and submit pictures as proof to LPA via text 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: 11/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2024


LIC809 (FAS) - (06/04)
Page: 5 of 10
Document Has Been Signed on 11/21/2024 03:00 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 11/21/2024 at 12:47 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: TRUST & GRACE ADULT CARE HOME
FACILITY NUMBER: 361800193

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2024

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 assistant administrator did not comply with the section cited above by not purchasing a surety bond which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2024
Plan of Correction
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Assistant Administrator stated that a surety bond will be purchased by POC due date and will send a copy via email to LPA.
Type B
Section Cited
CCR
80026(h)
Safeguards for Cash Resources, Personal Property and Valuables
(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the assistant administrator did not comply with the section cited above by not maintaining accurate P&I records with chronological receipts which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2024
Plan of Correction
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Assistant Administrator stated that he will review and correct the clients P&I ledgers and include the chronological receipts. Assistant administrator will submit a statement of understanding 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: 11/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2024


LIC809 (FAS) - (06/04)
Page: 6 of 10
Document Has Been Signed on 11/21/2024 03:00 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 11/21/2024 at 12:47 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: TRUST & GRACE ADULT CARE HOME
FACILITY NUMBER: 361800193

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(b)
Administrator Qualifications and Duties
(b) All adult residential facilities shall have a qualified and currently certified administrator.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the assistant administrator did not comply with the section cited above in having a qualified and currently certified administrator which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2024
Plan of Correction
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Assistant Administrator stated that he will have the administrator submit proof of their administrator's certificate renewal paperwork to LPA via email by POC due date.
Type B
Section Cited
CCR
85064(e)
Administrator Qualifications and Duties
(e) The administrator shall be on the premises the number of hours necessary to manage and administer the facility in compliance with applicable law and regulation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the assistant administrator did not comply with the section cited above by having the administrator be on the premises the number of hours necessary to manage and administer the facility in compliance which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2024
Plan of Correction
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Assistant administrator stated that the administrator's schedule will be modified with hours during the week in order to maintain and manage the facility in compliance. Assistant administrator stated that a copy of the updated weekly staff schedule will be sent to the 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: 11/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2024


LIC809 (FAS) - (06/04)
Page: 7 of 10
Document Has Been Signed on 11/21/2024 03:00 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 11/21/2024 at 12:47 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: TRUST & GRACE ADULT CARE HOME
FACILITY NUMBER: 361800193

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80068.3(a)
Modifications to Needs and Services Plan
(a) The licensee shall ensure that each client's written Needs and Services Plan is updated as often as necessary to assure its accuracy, but at least annually. These modifications shall be maintained in the client's file.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the assistant administrator did not comply with the section cited above by not ensuring that the clients IPP were updated annually which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2024
Plan of Correction
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Assistant administrator stated that he will request all clients updated IPP's and submit proof to LPA via email by POC due date.
Type B
Section Cited
CCR
80069(b)
Client Medical Assessments
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the assistant administrator did not comply with the section cited above by not having the physician's report for two clients which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2024
Plan of Correction
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Assistant administrator stated that he will have the two clients medical evaluated and submit a copy of the physician's report 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: 11/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2024


LIC809 (FAS) - (06/04)
Page: 8 of 10
Document Has Been Signed on 11/21/2024 03:00 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 11/21/2024 at 12:47 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: TRUST & GRACE ADULT CARE HOME
FACILITY NUMBER: 361800193

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(d)
Other Provisions
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee, administrator, or regulated individual shall sign and date the documentation to indicate that the plan has been reviewed and updated as necessary.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the assistant administrator did not comply with the section cited above by reviewing/updating the emergency disaster plan annually which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2024
Plan of Correction
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4
Assistant administrator stated that he will have the administrator review/update the emergency disaster plan and submit proof to LPA via email by POC due date.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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: 11/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2024


LIC809 (FAS) - (06/04)
Page: 9 of 10
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: TRUST & GRACE ADULT CARE HOME
FACILITY NUMBER: 361800193
VISIT DATE: 11/21/2024
NARRATIVE
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Food Service: LPA observed that the facility did not have 2 days of perishables and 7 days of nonperishables for the clients. Deficiency issued. Dishes, cups, and utensils were also stored properly.

Yards/Outside: One shaded patio, side gate with self-latching handle on the right side of the house that leads into the backyard. All outdoor pathways were free of obstructions.

Record Review: LPA reviewed administrator and staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA observed that the facility did not have a qualified and currently certified administrator. Deficiency issued. LPA observed and interviewed that the administrator is not in the premises the number of hours necessary to manage and administer the facility in compliance. Deficiency issued. LPA observed that the personnel records were missing health screenings, TB tests and trainings. Deficiency issued. LPA reviewed client files for admission agreements, updated physician reports, and needs and services plans. LPA observed that the IPP for all clients were not updated. Deficiency issued. LPA observed that two clients did not have a medical assessment. Deficiency issued. P & I funds was audited and did not match with records. LPA observed that the facility did not have accurate P&I records with chronological receipts. Deficiency issued. LPA reviewed facility's file for emergency drills, emergency disaster plan, and liability insurance. LPA observed that the facility did not have a surety bond. Deficiency issued. LPA observed that the emergency disaster plan was not reviewed/updated annually. Deficiency issued.

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 Assistant Administrator, Dameon Lester.

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

DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
LIC809 (FAS) - (06/04)
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