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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880596
Report Date: 02/26/2025
Date Signed: 02/26/2025 11:24:08 AM

Document Has Been Signed on 02/26/2025 11:24 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:CAROLINE STREETFACILITY NUMBER:
361880596
ADMINISTRATOR/
DIRECTOR:		SHAZET KNOWLESFACILITY TYPE:
735
ADDRESS:14461 CAROLINE STTELEPHONE:
(442) 249-1310
CITY:ADELANTOSTATE: CAZIP CODE:
92301
CAPACITY: 4CENSUS: 4DATE:
02/26/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
11:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michelle Echeverria made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with DSP Porsha Hull and was granted entry to the facility. The facility is an Adult Residential Facility (ARF) level 4I designated home vendor by Inland Regional Center.

The facility is a (4) bedrooms (3) bathrooms home and, with a kitchen/dining area, living room, laundry area, attached garage. LPA was accompanied by Porsha Hull and Patricia Akintoye to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 76 degrees Fahrenheit. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting. Bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. The hot water temperature tested within regulation at 120 degrees Fahrenheit. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, license, and administrator certificate were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. There was a designated space for client/staff files. LPA observed two smoking detector alarms out of service, main light in master bedroom not functioning, two bedroom window screens broken, and fire extinguisher not serviced annually. Deficiency issued.

Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a variety of food available for clients. Dishes, cups, and utensils were also stored properly.

Yard/Outside: One shaded patio furniture for outdoor seating along with (1) shed used for storage. Side gate with self-latching handle on the right 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: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/26/2025
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 02/26/2025 11:24 AM - It Cannot Be Edited


Created By: Michelle Echeverria On 02/26/2025 at 10:49 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
RIVERSIDE, CA 92507

FACILITY NAME: CAROLINE STREET
FACILITY NUMBER: 361880596

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/26/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(c)(1)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022.  (1) The Infection Control Plan shall include all of the following: 

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the administrator did not comply with the section cited above by not having a complete Infection Control Plan which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/05/2025
Plan of Correction
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Administrator stated that he will submit a copy of the completed Infection Control Plan to LPA via email by POC due date.
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, the Administrator did not comply with the section cited above by not addressing and repairing two smoking detector alarms out of service, main light in master bedroom not functioning, two bedroom window screens broken, and fire extinguisher not serviced annuallywhich poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2025
Plan of Correction
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Administrator stated that he will address and fix the two smoking detector alarms out of service, main light in master bedroom not functioning, two bedroom window screens broken, fire extinguisher and submit pictures of repairings and invoices to LPA via email by POC due date.
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: 02/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2025


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 02/26/2025 11:24 AM - It Cannot Be Edited


Created By: Michelle Echeverria On 02/26/2025 at 10:49 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
RIVERSIDE, CA 92507

FACILITY NAME: CAROLINE STREET
FACILITY NUMBER: 361880596

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/26/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(a)
Client Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the Administrator did not comply with the section cited above by not updating physician's report, IPP and SIRs which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/05/2025
Plan of Correction
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Administrator stated that he will update all clients records and send proof to LPA via email by POC due date.
Type B
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the Administrator did not comply with the section cited above by not having an Emergency Disaster Plan which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2025
Plan of Correction
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Administrator stated that he will complete an Emergency Disaster Plan and send a copy to LPA via email by POC due date.
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: 02/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 02/26/2025 11:24 AM - It Cannot Be Edited


Created By: Michelle Echeverria On 02/26/2025 at 10:49 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
RIVERSIDE, CA 92507

FACILITY NAME: CAROLINE STREET
FACILITY NUMBER: 361880596

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/26/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the Administrator did not comply with the section cited above by conducting quarterly disaster drills which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2025
Plan of Correction
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Administrator stated that he will submit a statement of understanding on regulation cited and send a copy to LPA via email 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: 02/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
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: CAROLINE STREET
FACILITY NUMBER: 361880596
VISIT DATE: 02/26/2025
NARRATIVE
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Record Review: LPA reviewed client files for admission agreements, updated physician reports, and needs and services plans. LPA observed all client records not updated with current physician's report, IPP and SIRs. Deficiency issued. LPA also reviewed staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. P & I funds was audited and matched with ledger. LPA observed that the facility did not have an Emergency Disaster Plan. Deficiency issued. LPA observed all pages missing from the Infection Control Plan except for the last page. Deficiency issued. LPA observed that the facility did not conduct quarterly emergency drills since 7/29/24. Deficiency issued.

Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D and appeal rights were discussed and copies were provided to DSP, Porsha Hull.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2025
LIC809 (FAS) - (06/04)
Page: 5 of 5