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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881290
Report Date: 05/29/2024
Date Signed: 05/29/2024 12:01:03 PM

Document Has Been Signed on 05/29/2024 12:01 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:GOLD DUST WAYFACILITY NUMBER:
361881290
ADMINISTRATOR/
DIRECTOR:		WOODS,PATRICIA ANNFACILITY TYPE:
735
ADDRESS:12517 GOLD DUST WAYTELEPHONE:
(323) 395-8594
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 4CENSUS: 4DATE:
05/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:25 AM
MET WITH:Keyera Hunter-StaffTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Michelle Echeverria arrived at the facility unannounced to conduct a required Annual visit. LPA was greeted by Staff, Keyera Hunter and later met with Administrator, Patricia Woods. LPA toured the facility inside and outside with staff.

The facility has 4 bedrooms, 2 bathrooms, a kitchen, dining area, living room, laundry room, attached garage, and backyard. The facility is vendorized by Inland Regional Center. LPA completed a walk through of facility, medication audit, P&I audit 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 72 degrees F temperature. LPA inspected clients bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. An adequate supply of linens stored in a closet in the main hallway of the residence. LPA inspected client bathrooms; bathrooms were clean and appliances were operating appropriately. LPA tested the water temperature in the bathroom faucet, which tested within regulation at 108.8 degrees F. The facility is equipped with operating fire extinguisher and smoke detectors. LPA observed that the facility did not have an activated carbon monoxide alarm. Technical violation issued. Posters such as; the personal rights, the CCL complaint poster, and disaster plans were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept locked. There was a designated locked storage space for client/staff files, first aid kit and medication. The facility had emergency supplies. There are no pools, bodies of water, firearms or ammunition. LPA observed that the carpet inside the facility was dirty with stains and the kitchen floor was coming apart. Administrator stated that the floors will be replaced on August 2024. Technical violation issued.
Yards/Outside:
One shaded patio, a side gate with self-latching handle on the right side of the house that leads into the backyard. All outdoor pathways were free of obstructions.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/29/2024
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 05/29/2024 12:01 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 05/29/2024 at 10:48 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: GOLD DUST WAY
FACILITY NUMBER: 361881290

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, and record review, the administrator did not comply with the section cited above in maintaining record of the turberculosis test for one staff which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/29/2024
Plan of Correction
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Administrator obtained the staff's immunization record showing proof of the tuberculosis test and included inside the staff's file.
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: 05/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024


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: GOLD DUST WAY
FACILITY NUMBER: 361881290
VISIT DATE: 05/29/2024
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Food Service: Non-perishable and perishable food supply is sufficient for clients in care. Dishes, cups, and utensils were also stored properly.

Record Review: LPA reviewed client files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA observed that staff present did not have record of Tuberculosis test. Deficiency issued. LPA observed the Emergency Disaster Plan not reviewed within a year. Technical violation issued.

One deficiency and three technical violations were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102TV and appeal rights were discussed and copies were provided to Administrator, Patricia Woods.

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

DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024
LIC809 (FAS) - (06/04)
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