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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880686
Report Date: 11/29/2023
Date Signed: 11/29/2023 05:14:14 PM

Document Has Been Signed on 11/29/2023 05:14 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:HELPING HEARTS BLACKWOODFACILITY NUMBER:
361880686
ADMINISTRATOR:CESAR ARGUETAFACILITY TYPE:
772
ADDRESS:11253 BLACKWOOD STTELEPHONE:
(909) 677-6644
CITY:FONTANASTATE: CAZIP CODE:
92337
CAPACITY: 6CENSUS: 4DATE:
11/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:32 PM
MET WITH:Arthur Estrada - Program DirectorTIME COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Anna Bueno made an unannounced visit to the facility to conduct a required annual inspection. LPA identified herself to behavioral health technicians (BHT) Daya Mercado and Mechella Williams who were informed of the purpose of the visit. BHTs phoned program director Arthur Estrada, who arrived during the visit. Two staff and all clients are present at the facility during today's visit.

LPA Bueno and BHT Mercado toured the interior and exterior of the facility. The facility has no bodies of water. There is a shaded area in the backyard for client use. LPA and BHT observed that side gate was unlocked and free of obstruction. The facility had a working telephone for use. The charged fire extinguishers were last inspected on 07/05/2023. Program Director Estrada tested all the bedroom smoke alarm and living room carbon monoxide detectors and found the all units to be in working order. A locked centralized cabinet is used for medications while client and staff files and facility records are kept secured. Sharps, toxins, and cleaning agents are kept secured and locked in closets and cabinets.

The following were observed of the physical plant:
Client Bedrooms and Bathroom: LPA Bueno and BHT Mercado observed all bedrooms to have the required bedding and furniture, such as, clean mattresses/linen, sufficient storage space, chairs, and lighting. LPA and BHT observed bathrooms being cleaned as part of house chores. Provisions for hygiene items are available.
Kitchen and Dining Areas: LPA and BHT inspected the kitchen and found dishes, glasses, and utensils were in good condition and stored in a safe manner. LPA and DSP inspected food provisions and found a 2-day supply of perishable food and 7-day supply of non-perishable food items.
Common (living/activity) areas: LPA and BHT observed adequate seating in the common areas. LPA observed board games and activities in the designated area. A schedule of activities is available for review.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2023
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 11/29/2023 05:14 PM - It Cannot Be Edited


Created By: Anna Bueno On 11/29/2023 at 04:51 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: HELPING HEARTS BLACKWOOD
FACILITY NUMBER: 361880686

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2023

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 LPA interview with Program Director, the licensee did not comply with the section cited above in that there is no record available to review for quarterly disaster drills which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/20/2023
Plan of Correction
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Licensee shall conduct disaster drills and log each event as required by regulation. Licensee shall submit proof of drill conducted no later than end of POC 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:Anna Bueno
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2023


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: HELPING HEARTS BLACKWOOD
FACILITY NUMBER: 361880686
VISIT DATE: 11/29/2023
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The following records were inspected:
Client Records: LPA Bueno inspected four client files and found all to have the required documentation, including but not limited to, placement and admissions agreement, physician's report, and needs and services plan.
Staff Records: LPA reviewed four staff files. Administrator certificate is current. LPA reviewed training logs.
Interview with Program Director found that disaster drills are being conducted however there is no record available for review.
Centralized Medication: LPA reviewed client medications. LPA observed all scheduled medications were administered as prescribed.

Program Director was not able to locate a record of disaster drill completed within the last quarter. This poses a potential health and safety risk to clients in care. Refer to LIC 809D for deficiency cited. An exit interview was conducted where this report was provided to program director Arthur Estrada at the conclusion of the inspection.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023
LIC809 (FAS) - (06/04)
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