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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800222
Report Date: 06/13/2023
Date Signed: 06/23/2023 03:59:19 PM

Document Has Been Signed on 06/23/2023 03:59 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:11772 JUSTINE WAYFACILITY NUMBER:
361800222
ADMINISTRATOR:SATTIEWHITE, KOLICEFACILITY TYPE:
735
ADDRESS:11772 JUSTINE WYTELEPHONE:
(760) 991-6602
CITY:ADELANTOSTATE: CAZIP CODE:
92301
CAPACITY: 4CENSUS: 4DATE:
06/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:22 PM
MET WITH:Shanellreya Knowles-ManagerTIME COMPLETED:
05:10 PM
NARRATIVE
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On 06/13/23 at 1:22 PM, Licensing Program Analyst (LPA) Michelle Echeverria arrived at the facility unannounced to conduct a required Annual visit. LPA was greeted and granted entrance by Manager, Shanellreya Knowles. LPA introduced self and stated the purpose of the visit. LPA observed that there are currently 3 residents in the facility and 1 resident in day program. Manager provided LPA with a tour of the facility.

The facility has 4 bedrooms, 2 bathrooms, a kitchen, dining area, living room, laundry room, garage and backyard. LPA conducted a general overall inspection, which included, but was not limited to, the following:

Physical Plant: There are no obstructions to indoor and outdoor passageways. The facility is maintained at a 69 degrees Fahrenheit temperature. LPA inspected residents bedrooms; they are equipped with required furniture per regulations. LPA observed insufficient amount of linens stored in the garage. Technical violation issued. LPA inspected residents bathroom; bathroom was clean and appliances were operating appropriately. LPA tested the water temperature in the kitchen faucet which tested at 113.2 degrees Fahrenheit. The facility is equipped with operating fire extinguisher, smoke alarms and carbon monoxide alarms. Posters such as; the personal rights, the CCL complaint poster, and disaster plans were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept locked. There was a designated locked storage space for residents files, first aid kit and medication. The facility has a working telephone line. There are no pools, bodies of water, firearms or ammunition.

Yards/Outside:
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.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 06/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2023
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 5
Document Has Been Signed on 06/23/2023 03:59 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 06/13/2023 at 03:57 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: 11772 JUSTINE WAY
FACILITY NUMBER: 361800222

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 80019(f) or

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 not requesting a criminal record clearance transfer for (S1) and (S2) which poses an immediate health, safety and personnal rights risk to persons in care.
POC Due Date: 06/14/2023
Plan of Correction
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Licensee will request a transfer of criminal record clearance for (S1) and (S2) to the facility's roster 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: 06/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/23/2023 03:59 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 06/13/2023 at 03:57 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: 11772 JUSTINE WAY
FACILITY NUMBER: 361800222

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(e)
Personnel Records
(e) All personnel records shall be maintained at the facility site.

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 not maintaining the personnel records in the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2023
Plan of Correction
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Licensee will maintain personnel records at the facility site 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: 06/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2023


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: 11772 JUSTINE WAY
FACILITY NUMBER: 361800222
VISIT DATE: 06/13/2023
NARRATIVE
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Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Facility has a wide variety of food available for residents. Dishes, cups, and utensils were also stored properly. Emergency food, water, supplies and emergency disaster kits were observed inside the garage.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPA reviewed 2 resident files for admission agreements, updated physician reports, and needs and services plans. LPA was not able to review staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings since the personnel records were not maintained at the facility. Deficiency issued. LPA observed that (S1) and (S2) are not added into the facility's roster. Deficiency issued. The facility last conducted a fire drill in May 08, 2023.

Deficiencies and technical violation were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102 and appeal rights were discussed and copies were provided to Manager, Shanellreya Knowles.

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

DATE: 06/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023
LIC809 (FAS) - (06/04)
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