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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881204
Report Date: 02/28/2024
Date Signed: 02/28/2024 04:42:57 PM

Document Has Been Signed on 02/28/2024 04:42 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:PITACHE RESIDENTIALFACILITY NUMBER:
361881204
ADMINISTRATOR:WILLIAMS, NATALIEFACILITY TYPE:
735
ADDRESS:18025 PITACHE ST.TELEPHONE:
(909) 671-2812
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY: 4CENSUS: 4DATE:
02/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Natalie Williams-AdministratorTIME COMPLETED:
04:50 PM
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On 2/28/24, Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with DSP, Jennifer Vargas and Abraham Robledo and introduced self and stated purpose of the visit. LPA was informed that there are 2 clients at home and 2 in program.

The facility has 4 bedrooms, 2 bathrooms, kitchen, living room, dining area, office/activity room, backyard, attached garage and 2 sheds. LPA completed a walk through of facility, review of records and P&I audit.

Physical Plant: There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 75 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 112.7 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, charged fire extinguisher and first aid kit. Posters such as; the personal rights, visitation rules and CCL complaint poster were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept locked and inaccessible to clients. There was a designated storage space for client/staff files. Medications was observed locked and inaccessible to clients. There is no swimming pool, bodies of water, firearms or ammunition in the facility. LPA observed the previous covered indoor patio converted into an activity/office room with a bedroom on the side occupied by an ambulatory client. Per the STD 850 approved on 11/4/21, bedroom 1 is for 2 nonambulatory, bedroom 2 is for 1 nonambulatory and bedroom 3 is for 1 nonambulatory. Fire inspection was not approved on the new bedroom added to the facility. Deficiency with civil penalty issued.

Food Service: Non-perishable and perishable food supply is not sufficient. DSP states that today is grocery shopping day. LPA observed Administrator, Natalie Williams order groceries and arrived during the inspection. Technical violation issued. Dishes, cups, and utensils were also stored properly.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2024
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 02/28/2024 04:42 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 02/28/2024 at 03:25 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: PITACHE RESIDENTIAL
FACILITY NUMBER: 361881204

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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 observation, interview and record review, the licensee did not comply with the section cited above in obtaining an approved fire clearance for the new bedroom occupied by a client which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/29/2024
Plan of Correction
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Licensee states that she will submit an LIC200, STD 850 and facility sketch to the regional office by POC due date and send a copy to LPA 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: 02/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024


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: PITACHE RESIDENTIAL
FACILITY NUMBER: 361881204
VISIT DATE: 02/28/2024
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Yards/Outside: One shaded outdoor table, side gate with self-latching handle on the right side of the house that leads into the backyard, and two sheds used for storage. All outdoor pathways were free of obstructions.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPA reviewed administrator and DSP files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA reviewed two client files for admission agreements, updated physician reports, and needs and services plans. P & I funds were counted at random and matched with the ledger. LPA reviewed facility's file for fire drills, infection control plan, and insurance policy.

One technical violation and one deficiency with civil penalty were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102TV and LIC421IM were discussed and copies were provided to Administrator, Natalie Williams who arrived after the facility tour.

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

DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024
LIC809 (FAS) - (06/04)
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