361800211-2-12-2025-56-AS-MMAE-DDTSGA-20250212125137

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361800211
Report Date: 02/12/2025
Date Signed: 02/12/2025 12:51:48 PM

Document Has Been Signed on 02/12/2025 12:51 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:	JHOLLY RANCH ADULT RESIDENTIAL HOME		FACILITY NUMBER:	361800211
ADMINISTRATOR/ DIRECTOR:	JOHNSON, LEE A		FACILITY TYPE:	735
ADDRESS:	35222 SHERMAN WAY		TELEPHONE:	(760) 248-2587
CITY:	LUCERNE VALLEY	STATE: CA	ZIP CODE:	92356
CAPACITY: 3		CENSUS: 3	DATE:	02/12/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Lee Johnson		TIME VISIT/ INSPECTION COMPLETED:	12:55 PM

NARRATIVE

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Licensing Program Analyst (LPA) Magda Malcore made a visit to the facility to conduct a required annual inspection. LPA met with Administrator, Lee Johnson and discussed the purpose of the visit. During today's visit there were no clients present. The facility is an Adult Residential facility with a license capacity of (3) and a current census (3). LPA conducted an overall inspection, which included, but was not limited to, the following:

Operation/Physical Plant: The facility maintains an infection control plan and emergency disaster plan on file for review. Indoor and outdoor passageways were kept free of obstruction. The facility has no swimming pools or similar bodies of water. The facility has sufficient covered outdoor activity space for clients in care. The facility has sufficient indoor activity areas for client activities and visitors. The facility is maintained at 68 degrees F. The facility is equipped with operating carbon monoxide alarms, fire extinguishers, first aid kits, laundry equipment, hallway night lights, and telephone service. The facility has a sufficient supply of bed linen, towels, and hygiene products for clients in care. The facility has posted in a common area: Community Care Licensing complaint poster, facility license, house rules, scheduled activities, client rights, and evacuation sketch. Client bedrooms were equipped with beds, bed linen, nightstands, chairs, and lighting. Client bathroom equipment were operating in a safe and sanitary condition. The hot water in client bathrooms tested at 115 degrees F. Disinfectants and cleaning supplies were stored in a locked cabinet.

Food Service: The facility’s dining and kitchen areas were maintained clean. The facility has sufficient non-perishable and perishable food for number of clients in care and includes fresh fruits, vegetables, and snacks. The facility has a posted menu in the dining/kitchen area.

Health Related Services: Client medications are centrally stored in a locked room. LPA's review of client #1 (C1's) medication reveals, one of C1's prescribed p.m. medication listed on record was missing. The Administrator stated that the medication was discontinued; however there was no documentation of physician's order to discontinue medication. Deficiency cited. **continued on next page**

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025

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 02/12/2025 12:51 PM - It Cannot Be Edited

Created By: Magda Malcore On 02/12/2025 at 11:48 AM

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: JHOLLY RANCH ADULT RESIDENTIAL HOME	FACILITY NUMBER: 361800211
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80075(b)(5)(A)

Health-Related Services

(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (A) There is written direction from a physician, on a prescription blank, specifying the name of the client, the name of the medication, all of the information specified in Section 80075(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication of when the physician should be contacted for a medication reevaluation. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observations, the licensee did not comply with the section cited above by not maintaining documentation of physician's order to discontinue medication for medication listed as current; which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/17/2025
	Plan of Correction
1 2 3 4	The Licensee/Administrator shall submit a state of understanding on the regulation cited 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:

Karen Clemons

LICENSING EVALUATOR NAME:

Magda Malcore

LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025

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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: JHOLLY RANCH ADULT RESIDENTIAL HOME	FACILITY NUMBER: 361800211
	VISIT DATE: 02/12/2025

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Personnel/Client Records: Staff records reviewed had health screenings, criminal record clearances, and first aid/CPR training certification. Client records reviewed had admission agreements, medical assessments, needs and service plans, and personal/incidental logs. Administrator's certification, facility insurance, and surety bond are current.

During today's visit, deficiencies were cited and technical advisories were issued per Title 22, California Code of Regulations.

An exit interview was conducted, where this report was discussed and a copy was provided to the Administrator with appeal rights at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025

LIC809 (FAS) - (06/04)

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