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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800210
Report Date: 04/05/2023
Date Signed: 04/05/2023 11:27:23 AM


Document Has Been Signed on 04/05/2023 11:27 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507



FACILITY NAME:ARIES RESIDENTIAL CARE INCFACILITY NUMBER:
361800210
ADMINISTRATOR:ROGOVIN, ROBERTFACILITY TYPE:
740
ADDRESS:17892 SYCAMORE STTELEPHONE:
(760) 821-9172
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY:6CENSUS: 6DATE:
04/05/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Herminia Rogovin, Licensee and
Robert Rogovin Licensee and Administrator		TIME COMPLETED:
11:35 AM
NARRATIVE
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On 04/05/2023 at 11:25 a.m., Licensing Program Analyst (LPA) Rayshaun Nickolas conducted a case management deficiency visit. The case management visit is in response to a deficiency cited at the facility. LPA met with the Rogovins and explained the purpose of the visit.

LPA observed the refrigerator in the kitchen with a device that prevents clients from opening the refrigerator door. LPA interview with the administrator revealed that the device was placed on the refrigerator door to prevent client # 1 (C1) access to the refrigerator because of their medical condition. LPA advised the administrator to obtain medical substantiation from C1's physician and to submit a waiver request to our agency.

Based on observations made during today, one (1) deficiency was cited per Title 22, Division 6, of the California Code of Regulations (CCR), Sections 87468.1(a)(3) Personal Rights of Residents in All Facilities.

An exit interview was conducted and a copy of this report, LIC 809D, and Appeal Rights were provided.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Rayshaun NickolasTELEPHONE: 951-255-9516
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2023
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 04/05/2023 11:27 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: ARIES RESIDENTIAL CARE INC
FACILITY NUMBER: 361800210

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/07/2023
Section Cited

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 87468.1 Personal Rights of Residents in All Facilities (a)(3)

(3) ....interfering with daily living functions such as eating, sleeping, or elimination.
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The Licensee shall remove this device from the refrigerator by the POC due date. The Licensee shall also submit a waiver request to Licensing with medical substaniation from C1's physician.
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This requirement was not met as evidenced by:

Based on observation, the Licensee did not ensure to obtain approval from Licensing before using a device to prevent clients from accessing the refrigerator.
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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: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Rayshaun NickolasTELEPHONE: 951-255-9516
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2023
LIC809 (FAS) - (06/04)
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