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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880602
Report Date: 05/16/2022
Date Signed: 05/16/2022 01:26:42 PM

Document Has Been Signed on 05/16/2022 01:26 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
, CA 92507
FACILITY NAME:IRIS STREETFACILITY NUMBER:
361880602
ADMINISTRATOR:JASPER WARDFACILITY TYPE:
735
ADDRESS:14733 IRIS STTELEPHONE:
(442) 249-1457
CITY:ADELANTOSTATE: CAZIP CODE:
92301
CAPACITY: 4CENSUS: DATE:
05/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Jasper WardTIME COMPLETED:
01:35 PM
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Licensing Program Analyst (LPA) Rayshaun Nickolas conducted an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. LPA Nickolas arrived and met with Administrator, Jasper Ward. LPA Nickolas was asked to sign-in and provide temperature reading upon arrival. The administrator confirmed that there are currently no cases/exposures of COVID-19 within the facility.

During the inspection, LPA Nickolas conducted a tour of the facility and made observations pertaining to the facility's infection control measures and other health and safety concerns. LPA Nickolas observed appropriate postings throughout the facility, including hand-washing etiquette, face coverings, and COVID-19 symptoms postings. The facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a supply of Personal Protective Equipment (PPE). LPA observed that the facility staff were wearing face coverings. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the facility's infection control measures. The facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolating/quarantining residents, and properly caring for residents with COVID-19 positive results and/or exposures. The facility also has a plan in place to monitor residents regularly for any changes in condition and to subsequently notify the resident's physician and emergency personnel in the event the resident presents any COVID-19 symptoms.

LPA observed a broken fence in the backyard. LPA observed broken furniture (sofa, dresser and patio furniture) and mattress in the backyard .LPA also observed less than one week of nonperishable foods and less than two days of perishable foods.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2022
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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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: IRIS STREET
FACILITY NUMBER: 361880602
VISIT DATE: 05/16/2022
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 Based on observations made during today’s inspection, two deficiency was cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted where this report was discussed, and a copy of this report was provided to Ward at the conclusion of the inspection
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/16/2022 01:26 PM - It Cannot Be Edited


Created By: Rayshaun Nickolas On 05/16/2022 at 12:25 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
, CA 92507

FACILITY NAME: IRIS STREET
FACILITY NUMBER: 361880602

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
80087 Buildings and Grounds
The facility shall be kept clean, sanitary and in good repair at all
times.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in ensuring that the facility is in good repair at all times. LPA observed a broken fence and funiture in the backyard. Which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/30/2022
Plan of Correction
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Licensee shall repair broken fence in the backyard. Licensee shall remove broken furniture (sofa, dresser and patio furniture) and mattress out of the backyard. Proof of Correction will be submitted to LPA by the closure of business on May 30, 2022.
Type B
Section Cited
CCR
85076(d)(1)
85076 Food Service
Supplies of staple nonperishable foods for a minimum of one
week and fresh perishable foods for a minimum of two days
shall be maintained on the premises.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation,the licensee did not comply with the section cited above by maintaining an adquate food supply. LPA observed less than one week of nonperishable and less than two days perishable food supply. Which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/17/2022
Plan of Correction
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Licensee shall maintain one week supply of nonpershable foods and two days of persihable foods. Proof of correction shall be submitted to LPA by the closure of business of May 17, 2022.
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:Karen Clemons
LICENSING EVALUATOR NAME:Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2022


LIC809 (FAS) - (06/04)
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