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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880908
Report Date: 05/16/2023
Date Signed: 05/16/2023 01:32:24 PM

Document Has Been Signed on 05/16/2023 01:32 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:BRECKENRIDGE HOMEFACILITY NUMBER:
361880908
ADMINISTRATOR:SAMSON, JESILINE CFACILITY TYPE:
735
ADDRESS:9087 BRECKENRIDGE AVETELEPHONE:
(760) 488-1533
CITY:HESPERIASTATE: CAZIP CODE:
92344
CAPACITY: 4CENSUS: 4DATE:
05/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Kayla Schopen- House ManagerTIME COMPLETED:
01:50 PM
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Licensing Program Analyst (LPA) Victoria Chitgian arrived unannounced to the facility for a required annual inspection. Facility is an Adult Residential Facility licensed for four (4) ambulatory clients. LPA met with House Manager Kayla Schopen. At the time of the visit, no clients were present at the facility.
LPA toured the facility inside and outside. Outdoor and indoor passageways were kept free of obstruction. The facility has charged fire extinguishers, operating fire alarm systems, and carbon monoxide detectors. LPA toured the kitchen. Food was stored in a safe and healthful manner. The facility had a two (2) day supply of perishable food items and seven (7) day supply of nonperishable food items. LPA toured the client bedrooms. The client bedrooms had the required furniture and functional lighting. The facility had a supply of additional linen and extra hygiene items for the clients. The facility has a first aid kit available. LPA observed no scissors in the First aid kit. Technical Violation issued. The last disaster drill was conducted on 3/1/2023. Cleaning supplies were stored in the storage and laundry areas. Centrally stored medications were kept in a safe and locked cabinet. LPA toured the client bathrooms. The hot water temperature in the client bathroom measured 118 degrees Fahrenheit. LPA observed emergency supplies in the garage. The outside of the facility had a shaded area with a bench, table and chairs. The facility does not have a pool or bodies of water. LPA reviewed staff and client files. Staff files had the required documentation including a health screening report and first aid/CPR certification. Client files had the required documentation including an admission's agreement, updated physician's reports, and appraisal/needs & services plans. LPA observed one client admission agreement was not signed, as required. Technical Violation issued. LPA reviewed medications. Medications were dispensed appropriately according to the physician's orders. Licensee has secured each consumer’s personal property and cash resources. LPA observed signs and postings in a common area. LPA did not see the visitation policy posted as required. Technical Violation issued. Sufficient staff are employed and present in the facility to meet the needs of the consumers in care.
No deficiencies were cited during this visit. Three(3) technical violations issued. An exit interview was conducted where this report was discussed and provided to the House manager Kayla Schopen, at the end of the visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Victoria Chitgian
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2023
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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