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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880602
Report Date: 05/18/2023
Date Signed: 05/18/2023 03:18:51 PM

Document Has Been Signed on 05/18/2023 03:18 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:PATRICIA ANN WOODSFACILITY TYPE:
735
ADDRESS:14733 IRIS STTELEPHONE:
(442) 249-1457
CITY:ADELANTOSTATE: CAZIP CODE:
92301
CAPACITY: 4CENSUS: DATE:
05/18/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:56 PM
MET WITH:Malissa King, caregiverTIME COMPLETED:
03:21 PM
NARRATIVE
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On May 18, 2023, at 2:56 p.m., Licensing Program Analyst (LPA) Rayshaun Nickolas visited the facility unannounced. The purpose of this visit is in response to complaint control number 56-AS-20230515152552 received by this agency on May 15, 2023 for another facility that the Licensee owns. LPA met with caregiver Malissa King and explained the purpose of the visit. LPA Nickolas' also discussed this report with Administrator Patricia Woods over the telephone. Woods was not at the facility and gave permission for King to sign this report.

LPA Nickolas’ interviews with multiple witnesses revealed that during a Cinco De Mayo celebration, a resident from another facility grabbed Sunny Delights, and staff #1 (S1) told them, “Put it back it is not yours”. LPA Nickolas interviews revealed that the resident responded, “Don’t talk to me like that, your not my boss”. The witnesses stated that S1 responded, “Who is your boss”, and “Who is this resident’s boss?”. The witnesses stated that the resident ignored S1, and S1 continued by stating that the resident must not like black people. The witnesses stated, eventually, the resident was triggered and went into behavior and called S1 derogatory names.

During LPA Nickolas’ investigation into complaint control number 56-AS-20230515152552, it was discovered that S1 did not work at the facility where the complaint was filed. The resident involved in the incident resided at that facility. Nickolas’ interviews confirmed that S1 did not work at that facility. LPA Nickolas’ file review revealed that S1 is an associated employee with this facility.

Based on interviews conducted and file review, one (1) deficiency was cited per Title 22, Division 6, of the California Code of Regulations (CCR), Sections 80072 (a)(3) Personal Rights.

An exit interview was conducted, where copies of LIC 809, LIC 809D, and due to technical issue a copy of this report will be emailed no later than Friday, May 19, 2023.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE: DATE: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/18/2023
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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Document Has Been Signed on 05/18/2023 03:18 PM - It Cannot Be Edited


Created By: Rayshaun Nickolas On 05/18/2023 at 01:18 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: 05/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/06/2023
Section Cited
CCR
80072(a)(3)

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80072 Personal Rights (a)(3)

To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat...

This requirement was not met as evidenced by:
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The Licensee shall ensure that all facility staff are trained on the cited section. The Licensee shall also forward training records with staff signatures to the regional office (RO) by the POC due date.
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Based on interviews and file review, the licensee did not ensure that facility staff treat residents in care with dignity and respect, which poses a potential health, safety, and personal rights violation to persons 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:Karen Clemons
LICENSING EVALUATOR NAME:Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2023


LIC809 (FAS) - (06/04)
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