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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881023
Report Date: 08/16/2023
Date Signed: 08/16/2023 04:09:15 PM

Document Has Been Signed on 08/16/2023 04:09 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:OAK HILLS RANCH RESIDENTIALFACILITY NUMBER:
361881023
ADMINISTRATOR:WALKER, JR., DANAFACILITY TYPE:
737
ADDRESS:10268 FREMONTIA DRIVETELEPHONE:
(909) 343-4004
CITY:OAK HILLSSTATE: CAZIP CODE:
92344
CAPACITY: 4CENSUS: 3DATE:
08/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:08 PM
MET WITH:Angela Calhoun- Assistant AdministratorTIME COMPLETED:
04:15 PM
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On 08/16/23, Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with Assistant Administrator, Angela Calhoun and introduced self and stated purpose of the visit. LPA was informed that there are currently 3 clients in care.

The facility has 3 client bedrooms, 3 bathrooms, office, front room, kitchen, dining area, living room, attached garage, and backyard. The facility is vendorized by Inland Regional Center. 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 77 degrees fahrenheit. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected client bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 105.1 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms and two charged fire extinguishers. Posters such as; the personal rights, emergency disaster plan and CCL complaint poster were posted in a common area. LPA observed that the emergency disaster plan has not been reviewed since 11/14/20. Technical violation issued. Cleaning supplies, toxins, sharps, and other dangerous items were kept in secure cabinets and drawers inaccessible to clients. There was a designated storage space for client/staff files. Medications and first aid kit were observed in secure cabinets and inaccessible to clients. The facility had emergency kits and emergency water inside the garage. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care.

Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a wide variety of food available for clients. Dishes, cups, and utensils were also stored properly.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2023
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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Document Has Been Signed on 08/16/2023 04:09 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 08/16/2023 at 03:17 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: OAK HILLS RANCH RESIDENTIAL
FACILITY NUMBER: 361881023

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 80019(f) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in requesting a transfer of a criminal record clearance for (4) staff which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/17/2023
Plan of Correction
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Licensee stated that she will submit and confirm the request of transferring the (4) staff's criminal record clearance into her facility. Licensee stated that she will submit a copy of Guardian showing the (4) added staff into the facility's roster by POC due date via email.
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:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2023


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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: OAK HILLS RANCH RESIDENTIAL
FACILITY NUMBER: 361881023
VISIT DATE: 08/16/2023
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Yards/Outside: One shaded patio, a side gate with self-latching handle on the left side of the house that leads into the backyard. All outdoor pathways were free of obstructions.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department.

Record Review: LPA reviewed 2 client files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed administrator's file and 2 staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA observed and reviewed that (4) staff criminal record clearance have not been transferred to the facility. Deficiency with civil penalty issued. The facility last conducted a fire drill on July 23, 2023.

One deficiency, one technical violation and civil penalty were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102, LIC421BG and appeal rights were discussed and copies were provided to the Assistant Administrator, Angela Calhoun.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023
LIC809 (FAS) - (06/04)
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