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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880567
Report Date: 11/22/2022
Date Signed: 11/22/2022 09:34:20 AM

Document Has Been Signed on 11/22/2022 09:34 AM - 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
, CA 92507
FACILITY NAME:YUCCA RESIDENTIALFACILITY NUMBER:
361880567
ADMINISTRATOR:NICOLE JOYNERFACILITY TYPE:
735
ADDRESS:16320 YUCCA AVETELEPHONE:
(760) 843-7676
CITY:VICTORVILLESTATE: CAZIP CODE:
92395
CAPACITY: 4CENSUS: 3DATE:
11/22/2022
TYPE OF VISIT:Case Management - DeficienciesANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Licensee/Administartor Diana RojasTIME COMPLETED:
09:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Melody Brown met with Licensee/Administrator Diana Rojas at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office 11/22/2022 at 8:30 AM to initiate a Case Management Office Visit. LPA Brown explained the purpose of the requested Office Visit. The investigation consisted of interviews and a review of pertinent documentation.

Interviews with staffs and client during the facility visit last 03/23/2022 at 12:00 PM indicated that Staff 4 (S4) used Crisis Prevention Intervention (CPI) to Client 1 (C1) last 02/28/2022 and 03/02/2022 due to C1’s aggressive behaviors that presents immediate danger to self and to others. However, per documents review, LPA Brown observed no debriefing occurred within 24 hours of the used of CPI last 02/28/2022 and 03/02/2022. LPA Brown explained to Administrator Rojas the importance of debriefing. In addition, interview with Staff 1 (S1) confirmed that the facility did not conduct debriefing regarding the incident last 02/28/2022 and 03/02/2022. Also, S1 reported during the interview of not being aware of debriefing procedure. LPA Brown will be issuing a deficiency for this issue as no documentation of debriefing was observed during the visit and this pose immediate risk to clients in care.

LPA Brown informed Administrator Rojas that debriefing includes involved client (C1), staff involved (S4) and a supervisor (Administrator) and if a client requested their authorized representative. Moreover, LPA Brown emphasized to Administrator Rojas that debriefing provides opportunity for both staff and client to discuss the circumstances resulting in the use of seclusion or restraint and strategies to be used by staff, client or others that could prevent future use and Administrator Rojas expressed understanding.

*** Continuation in LIC809C ***

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2022
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 4
Document Has Been Signed on 11/22/2022 09:34 AM - It Cannot Be Edited


Created By: Melody Brown On 11/22/2022 at 07:48 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
, CA 92507

FACILITY NAME: YUCCA RESIDENTIAL
FACILITY NUMBER: 361880567

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
11/23/2022
Section Cited
CCR
80065(i)(2)

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80065 Personnel Requirements (i) Prior to employment or initial presence in the facility, all employees... (2) Request a transfer of a criminal record clearance as specified... This requirement is not me as evidenced by:

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Licensee stated to submit Signed Statement of Understanding on CCR 80065(i)(2) to LPA Brown by POC due date.
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Based on interviews and record review, the Licensee did not comply with the section cited above by separating S4 at the facility 02/28/2022 and allowed S4 to work at the facility up to 03/11/2022 which pose immediate health, safety, and personal rights risks 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:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2022


LIC809 (FAS) - (06/04)
Page: 4 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: YUCCA RESIDENTIAL
FACILITY NUMBER: 361880567
VISIT DATE: 11/22/2022
NARRATIVE
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In addition, per documents review during the facility visit last 03/23/2022 indicated that Staff 4 have no documentation of completed CPI training. Interviews with S1 and S4 indicated S4 completed the CPI training but no document of training was found in S4 file. LPA Brown will be issuing a deficiency for this issue as this pose potential risk to clients in care.

Moreover, per documents review, LPA Brown observed that S4 have a current criminal background clearance but S4 was not associated to the facility due to S4 was separated to the facility 02/28/2022. Staff interviews and records review of Care Notes indicated S4 continued working at the facility up to 03/11/2022.

Civil Penalty was assessed with the amount of $500.00 during the Office Visit for failure to associate/transfer S4 Criminal Background Clearance to the facility from 03/01/2022 up to 03/11/2022 as S4 was reported separated at the facility as of 02/28/2022 .

An exit interview was conducted where this report (LIC809), LIC809D, LIC421BG and Appeal Rights were discussed and provided to Licensee/Administrator Diana Rojas.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 11/22/2022 09:34 AM - It Cannot Be Edited


Created By: Melody Brown On 11/22/2022 at 06:17 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
, CA 92507

FACILITY NAME: YUCCA RESIDENTIAL
FACILITY NUMBER: 361880567

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/23/2022
Section Cited
CCR
85168.3(a)

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85168.3 Manual Restraint or Seclusion Review (a) The Licensee shall ensure that a debriefing occurs in accordance with Section 1180.5(b) of the Health and Safety Code.
This requirement is not met as evidenced by:
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Licensee stated to submit Signed Statement of Understanding on CCR 85168.3 (a) to LPA Brown by POC due date.
Licensee stated to submit proof of All Staff In-Service Meeting/Training on CCR 85168.3 (a) to LPA Brown by POC due date.
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Based on interviews and record review, the Licensee did not comply with the section cited above by failure to conduct debriefing regarding the incident within 24 hours after the use of seclusion or restraint which pose immediate health, safety, and personal rights risks to clients in care.
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Type B
11/29/2022
Section Cited
CCR80066(a)(6)

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80066 Personnel Records (a) The Licensee shall ensure that personnel records are maintained …(6) Documentation of the educational background, training and/or experience as specified in…
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Licensee stated to submit Signed Statement of Understanding on CCR 80066(a)(6) to LPA Brown by POC due date.
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Based on interviews and record review, the Licensee did not comply with the section cited above by failure to document S4 CPI training in Staff File which pose potential 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:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2022


LIC809 (FAS) - (06/04)
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