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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530003
Report Date: 07/02/2024
Date Signed: 07/02/2024 06:19:52 PM

Document Has Been Signed on 07/02/2024 06:19 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:WINTER PARK HOMEFACILITY NUMBER:
365530003
ADMINISTRATOR/
DIRECTOR:		COLLINS, MICHAELFACILITY TYPE:
735
ADDRESS:16350 BURWOOD AVETELEPHONE:
(909) 573-7989
CITY:VICTORVILLESTATE: CAZIP CODE:
92395
CAPACITY: 4CENSUS: 4DATE:
07/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:12 PM
MET WITH:Jose Vallejo-CaregiverTIME VISIT/
INSPECTION COMPLETED:
06:29 PM
NARRATIVE
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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 Caregiver, Jose Vallejo. LPA observed that there are currently 4 clients at home. LPA toured the facility inside and outside with caregiver, Jose Vallejo.

The facility has 5 bedrooms, 2 bathrooms, a kitchen, dining area, living room, family room, laundry room, attached garage, and backyard. LPA conducted a general overall inspection, which included, but was not limited to, the following:

Physical Plant: There are no obstructions to indoor and outdoor passageways. The facility is maintained at a 78 degrees F temperature. LPA inspected clients bedrooms; they are equipped with required furniture per regulations. An adequate supply of linens stored in the hallway closet. LPA inspected clients bathroom; bathroom was clean and appliances were operating appropriately. LPA tested the water temperature in the bathroom which tested at 105.5 degrees F temperature. The facility is equipped with operating fire extinguisher, smoke detectors and carbon monoxide alarms. 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 clients/staff files, first aid kit and medication. There are no pools, bodies of water, firearms or ammunition. Overall, the facility is clean, in good repair, and operating in safe conditions.

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. There are fruit trees, vegetables and herbs planted in the back yard.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2024
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 4
Document Has Been Signed on 07/02/2024 06:19 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 07/02/2024 at 05:39 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: WINTER PARK HOME
FACILITY NUMBER: 365530003

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(f)
Administrator Qualifications and Duties
(f) When the administrator is absent from the facility there shall be coverage by a designated substitute, who meets the qualifications of Section 80065, who shall be capable, of, and responsible and accountable for, management and administration of the facility in compliance with applicable law and regulation.

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 having coverage for management and administration when the administrator was on vacation which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/12/2024
Plan of Correction
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Licensee stated that she will review the regulation cited and submit a statement of understanding and send proof to LPA via email by POC due date.
Type B
Section Cited
CCR
80072(a)
Personal Rights
(a) Except for children's residential facilities, each client shall have personal rights which include, but are not limited to, the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in violating the client's personal rights by locking the refrigerator with a chain lock which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/12/2024
Plan of Correction
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Licensee stated that she will remove the lock and submit a statement of understanding on the regulation cited and submit proof to LPA via email by POC due date
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: 07/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 07/02/2024 06:19 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 07/02/2024 at 05:39 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: WINTER PARK HOME
FACILITY NUMBER: 365530003

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(f)(2)(B)
Other Provisions
(f) A facility shall have both of the following in place: (2) A set of keys available for use during an evacuation that provides access to all of the following: (B) All facility vehicles.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in having a vehicle and set of keys available for disaster preparedness which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/12/2024
Plan of Correction
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Licensee stated that she will have a vehicle and keys available for disaster preparedness and submit proof to LPA via email by POC due date.
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: 07/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2024


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: WINTER PARK HOME
FACILITY NUMBER: 365530003
VISIT DATE: 07/02/2024
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Food Service: LPA observed 2 days of perishables and 7 days non-perishables food, pantry fully stocked and up to date. Facility has a variety of food available. Menu plan is posted on the kitchen's refrigerator. LPA observed the refrigerator doors inaccessible to the clients with a chain and lock attached. Deficiency issued. Dishes, cups, and utensils were stored properly. Emergency food and water were observed inside the garage.

Record Review: LPA reviewed administrator and staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA observed that the facility administrator's was on vacation and did not appoint a designated administrator during their absence. Deficiency issued. LPA reviewed all clients files for admission agreements, updated physician reports, and needs and services plans. LPA observed that the facility did not have a vehicle and keys available to use for disaster preparedness. Deficiency issued. P & I funds were counted at random and matched with the ledger. Medication was not audited due to timing.

Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D and appeal rights were discussed and copies were provided to caregiver, Jose Vallejo.

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

DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
LIC809 (FAS) - (06/04)
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