361880626-11-7-2023-56-AS-MECA-CXCUL9-20231107144022

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361880626
Report Date: 11/07/2023
Date Signed: 11/07/2023 02:40:34 PM

Document Has Been Signed on 11/07/2023 02:40 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	JCP COTTAGE		FACILITY NUMBER:	361880626
ADMINISTRATOR:	FRISCO SANRY		FACILITY TYPE:	740
ADDRESS:	14241 LA MIRADA ST		TELEPHONE:	(760) 780-0970
CITY:	VICTORVILLE	STATE: CA	ZIP CODE:	92392
CAPACITY:	6	CENSUS: 4	DATE:	11/07/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:53 PM
MET WITH:	Frisco Sanry- Administrator		TIME COMPLETED:	02:48 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 11/07/23, Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with Administrator, Frisco Sanry and introduced self and stated purpose of the visit. LPA was informed that there are currently 4 residents in care. The facility has 6 bedrooms, 2 bathrooms, kitchen, dining area, living room, laundry, backyard, and attached garage. LPA completed a walk through of facility and review of records. 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 74 degrees fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected resident bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 105.3 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, charged fire extinguisher and first aid kit. Posters such as; the personal rights, emergency disaster plan, CCL complaint poster and ombudsman were posted in a common area. LPA observed an outdated emergency disaster plan last reviewed on 10/19/2021. Technical violation issued. Cleaning supplies, toxins, sharps, and other dangerous items were kept locked and inaccessible to residents. There was a designated storage space for resident/staff files. Medications was observed locked and inaccessible to residents. There is no swimming pool, bodies of water, firearms or ammunition in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care. Food Service: Non-perishable and perishable food supply is sufficient for residents in care. Dishes, cups, and utensils were also stored properly.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

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 11/07/2023 02:40 PM - It Cannot Be Edited

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: JCP COTTAGE	FACILITY NUMBER: 361880626
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87470(c)(1)(D)

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 87208. (1) The Infection Control Plan shall include all of the following: (D) The licensee shall review the use of infection control procedures in the facility at least annually, if local government public health determines an epidemic outbreak has occurred, or if the review is requested by the local licensing agency. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the administrator did not comply with the section cited above in updating the infection control plan which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/21/2023
	Plan of Correction
1 2 3 4	Administrator stated that he will update the infection control plan and submit a copy to LPA via email by POC due date.

Type B

Section Cited

CCR

87506(b)

Resident Records

(b) Each resident's record shall contain at least the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the administrator did not comply with the section cited above in maintaining complete resident records which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/21/2023
	Plan of Correction
1 2 3 4	Administrator stated that he will complete and submit a copy of the forms with issues on the resident records 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	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/07/2023 02:40 PM - It Cannot Be Edited

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: JCP COTTAGE	FACILITY NUMBER: 361880626
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(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 residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the administrator did not comply with the section cited above in maintaining a log for the emergency drills performed which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/21/2023
	Plan of Correction
1 2 3 4	Administrator stated that he will create an emergency disaster drill log and submit proof to LPA via email by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

LIC809 (FAS) - (06/04)

Page: 3 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: JCP COTTAGE	FACILITY NUMBER: 361880626
	VISIT DATE: 11/07/2023

NARRATIVE

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Yards/Outside: One shaded patio, side gate with self-latching handle on the left and right side of the house that leads into the backyard and one shed used for storage.

Record Review: LPA reviewed staff and administrator files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA reviewed resident files for admission agreements, updated physician reports, and needs and services plans. LPA observed incomplete files for residents. Deficiency issued. LPA observed that the facility did not have an updated infection control plan. Deficiency issued. LPA observed that the facility does not maintain a log for the emergency drills performed. Deficiency issued.

Deficiencies and one technical violation were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102TV and appeal rights were discussed and copies were provided to Administrator, Frisco Sanry.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

LIC809 (FAS) - (06/04)

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