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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880929
Report Date: 12/11/2023
Date Signed: 12/11/2023 03:33:30 PM

Document Has Been Signed on 12/11/2023 03:33 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:DAWSON HOMES INC. ON GLENWOOD AVENUEFACILITY NUMBER:
361880929
ADMINISTRATOR:HAWTHORNE, KENDRAFACILITY TYPE:
735
ADDRESS:2464 N. GLENWOOD AVE.TELEPHONE:
(909) 875-8327
CITY:RIALTOSTATE: CAZIP CODE:
92377
CAPACITY: 4CENSUS: 1DATE:
12/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Francisca Villalon, House ManagerTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Dawson Homes, Inc. on Glenwood Avenue unannounced to conduct the Annual Inspection. LPA was greeted by House Manager, Francisca Viilalon. LPA introduced self and stated purpose of the visit. LPA was granted entry and asked to signed in while the Administrator was contacted. LPA spoke with Administrator, Kendra Hawthorne over the phone and stated the purpose of the visit. It was reported that there was one resident present during the visit, while the remaining three residents were still at their prospective day programs.

LPA was accompanied by the House Manager on a tour of the facility to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is approved for 4 ambulatory residents ages 18 to 59 years old. Pathways throughout the facility were unobstructed. The facility was maintained at 75 degrees. The facility is equipped with operational smoke detectors and carbon monoxide alarms. Extra linens and towels were observed in a hallway closet - sufficient for the amount of residents in care. Another closet was utilized to hold residents activities. Posted in a prominent place LPA observed posters for LET-US-KNOW, staff cleaning routines, resident council meetings, upcoming fire drills, facility food menu, schedule for the day, infection control, resident rights, disaster plans and Labor Laws. Administrator reports fire/disaster drills are conducted on a monthly basis. Last drill conducted November 15th, 2023. At approximately, 2:15pm LPA observed the dry wall along side the bathroom wall. The dry wall was broken and cracked in a circular shape. It was reported that this was done as result of a resident's behavior. LPA observed resident rooms, each room included a mattress (with all required linens) adequate seating, sufficient lighting and storage. Additionally all rooms appeared neat and orderly. Night-lights were also observed throughout the facility. LPA observed adequate seating in the living and dining rooms. At approximately 2:25pm LPA tested the hot water temperature in the kitchen.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 7
Document Has Been Signed on 12/11/2023 03:33 PM - It Cannot Be Edited


Created By: Amber Coleman On 12/11/2023 at 02:28 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
RIVERSIDE, CA 92507

FACILITY NAME: DAWSON HOMES INC. ON GLENWOOD AVENUE
FACILITY NUMBER: 361880929

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations the licensee did not comply with the section cited above by not ensuring the facility's fire extinguishers were inspected on an annual basis which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/11/2024
Plan of Correction
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Administrator agrees to either purchased new fire extinguishers and place them in the facility or have the facility's current fire extinguishers inspected within the next 30 days. Additionally, send verification to the Community Care Licensing Office within 30 days.
Type B
Section Cited
CCR
80022(e)(4)
Plan of Operation
(e) If the licensee intends to admit or care for one or more clients who rely upon others to perform all activities of daily living, the plan of operation must also include a statement that demonstrates the licensee's ability to care for these clients. The evidence of ability may include but not be limited to: (4) Documentation of training the licensee and/or staff have completed specific to the needs of these clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based ona review of records the licensee did not comply with the section cited above in 4 out of 5 staff records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/11/2024
Plan of Correction
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Administrator agrees to take inventory of all missing trainings from each staff file and advise staff to complete the missing training records, obtain verifications and maintain them with in the staff file. Administrator agrees to send verification of the completed trainings to the Community Care Licensing Office within 30 days. [CPR/First Aid]
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:Amber Coleman
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2023


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 12/11/2023 03:33 PM - It Cannot Be Edited


Created By: Amber Coleman On 12/11/2023 at 02:28 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
RIVERSIDE, CA 92507

FACILITY NAME: DAWSON HOMES INC. ON GLENWOOD AVENUE
FACILITY NUMBER: 361880929

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80068(a)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record reviews the licensee did not comply with the section cited above in four out of four resident records which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/11/2024
Plan of Correction
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Administrator agrees to locate and/or draft admissions agreements for each of the residents, have them completed by the family or the residents and place them in the resident's files. Administrator agrees to send verification of the completed trainings to the Community Care Licensing Office within 30 days.
Type B
Section Cited
CCR
80069(b)
Client Medical Assessments
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record reviews the licensee did not comply with the section cited above in four out of four resident files; which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/11/2024
Plan of Correction
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Adminsitrator agrees to assist the four residents to make and keep doctor appointments, have each other their Physician's complete a Physician's Reports completed and placed in their resident file. Administrator agrees to send verification of the completed trainings to the Community Care Licensing Office within 30 days.
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:Amber Coleman
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2023


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 12/11/2023 03:33 PM - It Cannot Be Edited


Created By: Amber Coleman On 12/11/2023 at 02:28 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
RIVERSIDE, CA 92507

FACILITY NAME: DAWSON HOMES INC. ON GLENWOOD AVENUE
FACILITY NUMBER: 361880929

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(b)(1)(A)1
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (1) In adult CCFs, facility staff who receive training may assist clients with metered-dose inhalers, and dry powder inhalers if the following requirements are met: (A) In ARFs, facility staff must recieve training from a licensed proessional. 1. The licensee shall obtain written documentation from the licensed professional outlining the procedures and the names of facility staff who have been trained in those procedures.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record reviews the licensee did not comply with the section cited above by not ensuring that all staff files reamined in complaince with maintaining staff files and ensuring each staff file included verification/proof of training compleed. This poses a potential health, safety or personal rights risk.


in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/11/2024
Plan of Correction
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Administrator agrees to take inventory of all missing trainings from each staff file and advise staff to complete the missing training records, obtain verifications and maintain them with in the staff file. Administrator agrees to send verification of the completed trainings to the Community Care Licensing Office within 30 days.
Type B
Section Cited
HSC
80087(a)
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations the licensee did not comply with the section cited above by ensuring the facility remained in good repair when the dry wall was cracked and broken near the bathrooms door in the facility hallway; which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/11/2024
Plan of Correction
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Administrator agrees to have the dry wall by the hallway bathroom fixed to get the facility back into good condition. Administrator also agrees to send verification of this to the Community Care Licensing Office; within the next 30 days.
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:Amber Coleman
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2023


LIC809 (FAS) - (06/04)
Page: 4 of 7
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: DAWSON HOMES INC. ON GLENWOOD AVENUE
FACILITY NUMBER: 361880929
VISIT DATE: 12/11/2023
NARRATIVE
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Water temperature ranged between 115 to 128 degrees Fahrenheit. In the garage, the facility securely maintains the facility vehicle, washer/dryer, extra chemicals/toxins and the emergency food and water supplies. Another secure cabinet was located in the garage, this is where the resident's medications are kept. Resident and staff files are kept in the staff lounge area in secure file cabinets. There are two bathrooms. Each bathroom was equipped with handrails, non-slip grip rugs, and adequate amounts of hand hygiene supplies

Food Service: LPA observed the facility pantry; which included sufficient amounts of canned goods and nonperishable foods. All found in good standing. LPA observed the facility refrigerators and deep freezer well stocked with fruit, leftovers, milk, eggs, water, condiments and juices. Sufficient amounts of both perishable for the number of residents in care. Dishes, cups, and utensils were also observed well maintained and properly stored. LPA observed a fully charged fire extinguisher, last inspected March 2023; in the near the rear exit; along side the evacuation and emergency information.



Records: LPA reviewed four, (4) resident files for admission agreements, updated physician reports, and needs and services plans. 4 out of 4 resident files were missing up to date physician's reports and admissions agreements. LPA located Individual Program Plan's plans indicating needs and services. LPA reviewed five, (5) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. 4 out of 5 staff were missing complaint first aid/CPR. The remaining staff records included criminal record/fingerprint clearances and health screenings.

Based on observations, interviews and record reviews deficiencies will be cited per Title 22, California Code of Regulations to address the above mentioned concerns. An exit interview was conducted were this report was discussed, reviewed, and then provided to facility representative.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023
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