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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800205
Report Date: 08/29/2023
Date Signed: 08/29/2023 05:07:49 PM

Document Has Been Signed on 08/29/2023 05:07 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:ESPINOZA ADULT CARE HOME IIFACILITY NUMBER:
361800205
ADMINISTRATOR:LYDIA ESCTIAFACILITY TYPE:
735
ADDRESS:12799 PETALUMA RDTELEPHONE:
(909) 770-3544
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 4CENSUS: 4DATE:
08/29/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Justin Medina-House ManagerTIME COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michelle Echeverrria conducted an unannounced case management visit to follow up on an incident report sent to licensing dated on 08/17/23. The incident involved Client 1 (C1) taking $100.00 from his P&I funds along with $300.00 from Client 2 (C2) P&I funds while house manager was logging in the receipts when Client 3 (C3) spilled a drink nearby. LPA was greeted and explained the reason for the visit to house manager, Justin Medina.

During today's visit, it was discovered that the house manager failed to safeguard the clients P&I funds while cleaning the spill and maintain accurate P&I records for each client. Deficiency issued.

Deficiency issued during this visit. An exit interview was conducted where this report LIC809, LIC809D and appeal rights were, reviewed, discussed and provided to house manager, Justin Medina.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2023
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 2
Document Has Been Signed on 08/29/2023 05:07 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 08/29/2023 at 04:32 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: ESPINOZA ADULT CARE HOME II
FACILITY NUMBER: 361800205

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/05/2023
Section Cited
CCR
80026(b)

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80026(b) Safeguards for Cash Resources, Personal Property, and Valuables of Residents
(b) If such a client is accepted for or maintained in care, his/her cash... specified in (c) through (n) below. This requirement is not met as evidenced by:
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House manager stated that he will review regulation 80026(b), submit a statement of understanding to LPA via email by POC due date. House manager stated that he will maintain an accurate P&I record with emphasis on "out of pocket" receipts for all clients in care.
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Based on observation, interviews, and records review, the house manager did not comply with the section cited above by not safeguarding the clients cash resources and maintaining accurate records which poses a potential health, safety or personal rights risk to clients in care.
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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: 08/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2023


LIC809 (FAS) - (06/04)
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