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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880908
Report Date: 11/22/2023
Date Signed: 11/22/2023 10:54:25 AM

Document Has Been Signed on 11/22/2023 10:54 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, 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:
11/22/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Arvin Sarroca-LincenseeTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Michelle Echeverria arrived at the facility unannounced to conduct a Case Management Visit. This case management visit is in response to a Special Incident Report (SIR) submitted to the Community Care Licensing Office on 11/06/23. LPA was greeted and met by Elsie Strain at the front door. LPA introduced self and stated purpose of the visit.

On 10/27/23, IRC received a call from client's family stating that client had pulled a knife on the staff.

During today's visit, LPA met with Staff to discuss the incident and surrounding events. LPA did a health and safety check, interviewed clients and staff and reviewed records. During record review, it was discovered that the facility did not report the incident to the regional office.

Deficiency was issued during this visit. An exit interview was conducted where this report LIC809, LIC809D and appeal rights were, reviewed, discussed and then provided to Licensee, Arvin Sarroca who later arrived.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2023
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 11/22/2023 10:54 AM - It Cannot Be Edited


Created By: Michelle Echeverria On 11/22/2023 at 10:36 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: BRECKENRIDGE HOME
FACILITY NUMBER: 361880908

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/06/2023
Section Cited
CCR
80061(b)

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80061(b) Reporting Requirements
(b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1)... the licensing agency within seven days following the occurrence of such event. This requirement is not met as evidenced by:
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Licensee stated that he will have a meeting with staff going over regulation CCR 80061(b) and submit an attendance sheet signed by staff to LPA via email by POC due date.
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Based on observation, interviews, and records review, the licensee did not comply with the section cited above by not reporting to the regional office about the incident that had occurred which poses a potential health, safety or personal rights risk to clients 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:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2023


LIC809 (FAS) - (06/04)
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