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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800222
Report Date: 01/23/2024
Date Signed: 01/23/2024 03:00:03 PM

Document Has Been Signed on 01/23/2024 03:00 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:SHANELLREYA KNOWLESFACILITY TYPE:
735
ADDRESS:11772 JUSTINE WYTELEPHONE:
(760) 991-6602
CITY:ADELANTOSTATE: CAZIP CODE:
92301
CAPACITY: 4CENSUS: 4DATE:
01/23/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:17 AM
MET WITH:Shanellreya Knowles-AdministratorTIME COMPLETED:
03:05 PM
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Licensing Program Analyst (LPA) Michelle Echeverria conducted an unannounced visit to this facility to initiate an investigation of complaint number: 56-AS-20240116135003. LPA met with Administrator, Shanellreya Knowles.

During today's visit, LPA conducted interviews with residents, staff, obtained and reviewed facility records, and did a walk-through of the facility. LPA found the following issues:
  • Staff #4 (S4) working in the facility without criminal background clearance.
  • Insufficient quantity of linen to permit changing once a week or more often when necessary.
  • Insufficient detergent and necessary supplies needed for laundry operation.
These pose an immediate and potential health and safety risk to residents in care. Refer to LIC 809D for deficiencies cited.

An exit interview was conducted where this report, LIC809D, LIC421BG and appeal rights were discussed with and provided to Administrator, Shanellreya Knowles.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2024
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 3
Document Has Been Signed on 01/23/2024 03:00 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 01/23/2024 at 01:43 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: 01/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/23/2024
Section Cited
CCR
80019(e)(2)

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80019 Criminal Record Clearance
(e) All individuals subject to a criminal record..licensed facility:(1) Submit a valid mailing..the Department. (A) An individual who holds a..mailing address. (2) Obtain a California clearance...Department or. This requirement is not met as evidenced by:
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Administrator stated that staff 4 (S4) will be removed from the schedule until criminal clearance has been approved. Administrator stated that she and the licensee will review the regulation cited and submit a statement of understanding to LPA via email by 02/06/2024.
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Based on observation, interview and record review, the administrator did not comply with the section cited above in requesting a criminal record clearance for (S4) which poses an immediate health, safety and personnal rights risk to persons 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: 01/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 01/23/2024 03:00 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 01/23/2024 at 01:57 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: 01/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/26/2024
Section Cited
CCR
85088(c)(4)(A)

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85088(c)(4)(A) Fixtures, Furniture, Equipment and Supplies
(c) The licensee shall ensure provision to ....hygiene. (4) Clean linen in good repair, including...and washcloths. (A) The quantity of linen provided...all times. This requirement is not met as evidenced by:
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Administrator stated that she will purchase sufficient quantity of linen to be able to permit changing once a week or when necessary. Administrator will submit a picture of items and receipt via email by POC due date.
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Based on observation, the administrator did not comply with the section cited above in maintaining a sufficient quantity of linen in the facility which poses a potential health, safety or personal rights risk to persons in care.
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Type B
01/26/2024
Section Cited
CCR85088(d)

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85088(d) Fixtures, Furniture, Equipment and Supplies
(d) If the facility operates its own laundry, necessary supplies shall be available and equipment shall be maintained in good repair. This requirement is not met as evidenced by:
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Administrator stated that she will purchase detergent and the necessary supplies to operate laundry and submit a picture of items and receipt to LPA via email by POC due date.
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Based on observation, the administrator did not comply with the section cited above in maintaining a sufficient supply of detergent and other supplies needed for laundry operation which poses a potential health, safety or personal rights risk to persons 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: 01/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2024


LIC809 (FAS) - (06/04)
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