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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800222
Report Date: 08/24/2021
Date Signed: 08/24/2021 02:11:25 PM

Document Has Been Signed on 08/24/2021 02:11 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
CCLD Regional Office, 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:
08/24/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:22 PM
MET WITH:Shanell KnowlesTIME COMPLETED:
02:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Stephanie Williams made an unannounced visit to the facility in order to deliver findings for complaint control #18-AS-20210818110654. LPA met with House Manager, Shanell Knowles, and discussed the purpose of the visit.

During the complaint visit, LPA Williams discovered that an incident report was not submitted to the appropriate Community Care Licensing Division regional office for confirmed carbon monoxide exposure in the facility. There were approximately 4 clients in the facility at the time of the incident. LPA interviewed Knowles who stated that an incident report was not sent to the office. LPA reviewed the office duty log which did not show incident report submitted by facility. A deficiency will be issued for reporting requirements.

An exit interview was conducted where this report was discussed and a copy was provided to the House Manager.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Stephanie Williams
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2021
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 08/24/2021 02:11 PM - It Cannot Be Edited


Created By: Stephanie Williams On 08/24/2021 at 01:30 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: 08/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/31/2021
Section Cited
CCR
80061(b)(1)(E)

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80061 Reporting Requirements (b) Upon the occurrence, ... (2) below shall be submitted to the licensing agency within seven days... (1) Events reported shall include the following: (E) Any unusual incident.. which threatens the physical health or safety of any client. This requirement is not met as evidenced by:

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The licensee shall send incident report of carbon monoxide exposure dated 8/17/2021 to appropriate regional office. The licensee shall also send a letter of understanding of regulation 80061 reporting requirements by POC date of 8/31/2021.
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Based on interviews with staff, the facility did not submit incident report to appropriate regional office of confirmed carbon monoxide exposure within facility. This is a potential health and safety 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:Efren Malagon
LICENSING EVALUATOR NAME:Stephanie Williams
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2021


LIC809 (FAS) - (06/04)
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