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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530014
Report Date: 11/29/2023
Date Signed: 11/29/2023 02:34:18 PM

Document Has Been Signed on 11/29/2023 02:34 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:LONG MEADOW HOMEFACILITY NUMBER:
365530014
ADMINISTRATOR:CARR JR., MICHAELFACILITY TYPE:
735
ADDRESS:13170 LONG MEADOW ST.TELEPHONE:
(818) 309-7821
CITY:HESPERIASTATE: CAZIP CODE:
92344
CAPACITY: 4CENSUS: 4DATE:
11/29/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Erika Carr- LicenseeTIME COMPLETED:
02:40 PM
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Licensing Program Analyst (LPA) Michelle Echeverria arrived at the facility unannounced to conduct a Case Management Visit. This case management visit is in response to a Special Incident Report (SIR) submitted to the Community Care Licensing Office on 10/31/23. LPA was greeted and met by Staff Aidelada Villela at the front door. LPA introduced self and stated purpose of the visit.

On 10/26/23, Administrator performed a medication audit and noticed that medication had not been given to one client from 10/20/23-10/25/23 due to staff marking medication as discontinued on MARS and not checking for back-up supply.

During today's visit, LPA met with Licensee in the office who later arrived to discuss the incident and surrounding events. LPA interviewed and reviewed records. During interview and records review, it was discovered that medication training was given to staff on 11/15/23 and the staff with the medication error resigned on 10/27/23.

No deficiency was issued during this visit. An exit interview was conducted where this report LIC809 was reviewed, discussed and then provided to Licensee, Erika Carr.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2023
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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