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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880602
Report Date: 06/06/2024
Date Signed: 06/20/2024 10:22:40 AM

Document Has Been Signed on 06/20/2024 10:22 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:IRIS STREETFACILITY NUMBER:
361880602
ADMINISTRATOR/
DIRECTOR:		PATRICIA ANN WOODSFACILITY TYPE:
735
ADDRESS:14733 IRIS STTELEPHONE:
(442) 249-1457
CITY:ADELANTOSTATE: CAZIP CODE:
92301
CAPACITY: 4CENSUS: 4DATE:
06/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:13 AM
MET WITH:Patricia Woods AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analysts (LPA) Sarina Ramirez and Magda Malcore conducted an unannounced required annual inspection to the facility. LPAs met with Administrator, Patricia Woods and discussed the purpose of the visit.

The facility is an Adult Residential Facility (ARF),Level 4. The facility is an Inland Regional Center (IRC) certified vendor with a license capacity of (4) and a current census of (4). During the visit, three clients were present and one (1) client was attending Day Program. LPAs conducted an overall inspection of the facility, which included, but was not limited to, the following:

Physical Plant & Operation: Indoor and outdoor passageways are free of obstruction. The facility has no outdoor bodies of water accessible to clients in care. Facility's backyard is enclosed and gated. Indoor and outdoor activity areas are sufficient for clients in care. Client activities include board games, watching movies, community outings and Day program participation. The facility has sufficient lighting and is maintained at a comfortable temperature. Client bathrooms were operating in sanitary conditions.The hot water temperature in client bathrooms measures at 125 degrees F, a deficiency issued. Client bedrooms have sufficient lighting and furniture in good repair. Facility has operating carbon monoxide alarms, laundry equipment and telephone service. The facility has sufficient linen and personal hygiene items for clients in care. The facility has posted in a common area client registry, client personal rights, and disaster evacuation plan and emergency telephone numbers.


Food Service: Facility has sufficient non-perishable and perishable food supply for clients in care. Sharps, cleaning solutions and other toxins were kept locked. The facility has sufficient cups, plates, and utensils for client use.
** Continuation on LIC809-C**
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 06/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2024
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: IRIS STREET
FACILITY NUMBER: 361880602
VISIT DATE: 06/06/2024
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Care & Supervision: Facility has 24 hour care staff.

Record Review: Review all client files were observed, Client #1 (C1) signed admission agreement is missing, technical advisory issued. The Administrator's certification expires on 3/30/2026. Review of five (5) staff files reveals, the facility did not maintain an updated CPR training certification for Staff #1 (S1's), technical advisory issued.

Medical Related Services: All client medication is centrally stored and kept in a locked cabinet.

Based on observations and record review, a deficiency is being cited per Title 22, Division 6 of The California Code of Regulations.

An exit interview was conducted where the Licensing reports were discussed and copies of the reports with Appeal Rights was provided to the Administrator at the conclusion of the visit.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/20/2024 10:22 AM - It Cannot Be Edited


Created By: Sarina Ramirez On 06/06/2024 at 11:49 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: IRIS STREET
FACILITY NUMBER: 361880602

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation the licensee did not comply with the section cited above by hot water temperature in client bathrooms measures at 125 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/07/2024
Plan of Correction
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Licensee stated she will provide proof that the water is in regulation 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:Karen Clemons
LICENSING EVALUATOR NAME:Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2024


LIC809 (FAS) - (06/04)
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