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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880547
Report Date: 02/21/2023
Date Signed: 02/21/2023 02:48:26 PM


Document Has Been Signed on 02/21/2023 02:48 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:DESERT HORIZON RESIDENTIAL CAREFACILITY NUMBER:
361880547
ADMINISTRATOR:SHATTLES=BREEDLOVE, ANGELAFACILITY TYPE:
740
ADDRESS:15952 CONDOR RDTELEPHONE:
(760) 552-4352
CITY:VICTORVILLESTATE: CAZIP CODE:
92394
CAPACITY:8CENSUS: 5DATE:
02/21/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:34 AM
MET WITH:Emma Robinson-CaregiverTIME COMPLETED:
02:55 PM
NARRATIVE
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On this day, Licensing Program Analysts (LPAs) Michelle Echeverria and Anna Bueno conducted an unannounced visit to this facility to continue investigation on complaint 56-AS-20230208144257 and initiate an investigation of complaint number: 56-AS-20230213153122, 56-AS-20230216105026 and 56-AS-20230217100751.

During the investigation of complaint 56-AS-20230208144257. Refer to LIC809-D for deficiency cited. Violation discovered is listed below:
  • Improper medication storage.
  • Staff records did not have CPR/First Aid Training Certification


An exit interview was conducted with and a copy of this report, LIC809-D were provided to caregiver, Henrietta Chavez .
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle EcheverriaTELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2023
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 2


Document Has Been Signed on 02/21/2023 02:48 PM - 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: DESERT HORIZON RESIDENTIAL CARE
FACILITY NUMBER: 361880547

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/13/2023
Section Cited

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Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
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Upon observation of PRN medication found in kitchen pantry, Staff (S1) immediately removed PRN medication and placed it in staff's bedroom.
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This requirement was not met as evidence by
LPA discovering Staff's (S1) PRN medication placed in kitchen pantry.

This poses a potential health and safety risk to residents in care.
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Type B
02/16/2023
Section Cited

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Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
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LPA received proof of Staff's (S2) CPR/First Aid training certification completed on 02/16/2023 at 10:05 AM via email.
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This requirement was not met as evidence by
LPA discovering missing S2 CPR/First Aid training from S2's file.

This poses a potential health and safety risk to residents 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 BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle EcheverriaTELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2