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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530037
Report Date: 11/06/2024
Date Signed: 11/06/2024 12:30:36 PM

Document Has Been Signed on 11/06/2024 12:30 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:NEW HAVENFACILITY NUMBER:
365530037
ADMINISTRATOR/
DIRECTOR:		JOSE, JOSEPHFACILITY TYPE:
735
ADDRESS:13019 LEAWOOD STREETTELEPHONE:
(760) 262-5931
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 4CENSUS: 4DATE:
11/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Dinah Pasco- StaffTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with Staff, Dinah Pasco and introduced self and stated purpose of the visit. LPA was informed that there is 1 client in program and 3 at home.

The facility has 5 bedrooms, 3.5 bathrooms, kitchen, 2 dining areas, living room, family room, loft, office, laundry, backyard, and attached garage. LPA completed a walk through of facility, review of records, medication and P&I audit.

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 69 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 107.1 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, charged fire extinguishers and first aid kit. Posters such as; the personal rights, CCL complaint poster, disaster plans and license were posted in a common area. Most cleaning supplies, toxins, sharps, and other dangerous items were kept in secure cabinets and drawers inaccessible to clients. LPA observed an unlocked cabinet housing knives in the kitchen and an unlocked cabinet with cleaning products in the laundry room. Deficiency issued. 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 that incoming/outgoing calls could not be completed on the facility's landline telephone. Deficiency issued. 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. Facility has a wide variety of food available. Dishes, cups, and utensils were also stored properly.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2024
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 5
Document Has Been Signed on 11/06/2024 12:30 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 11/06/2024 at 11:23 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: NEW HAVEN
FACILITY NUMBER: 365530037

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the administrator did not comply with the section cited above by leaving the cabinets with knives and cleaning products accessible to clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/06/2024
Plan of Correction
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Staff immediately made the knives and cleaning products inaccessible to clients. Administrator stated that he will conduct a training with staff and submit the attendance sheet to LPA via email by 11/20/24.
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: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2024


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 11/06/2024 12:30 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 11/06/2024 at 11:23 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: NEW HAVEN
FACILITY NUMBER: 365530037

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80073(a)
Telephones
(a) All facilities shall have telephone service on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the administrator did not comply with the section cited above by providing a functioning landline telephone for the clients which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/20/2024
Plan of Correction
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Administrator stated that he will have the telephone landline serviced and activated. Administrator will submit invoice/contract to LPA via email by POC due date.
Type B
Section Cited
CCR
80066(a)(10)
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: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the administrator did not comply with the section cited above by providing proof of two staff's health physical test completed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/13/2024
Plan of Correction
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Administrator stated that he will have the two staff see a physician to obtain a health physical test 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: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 11/06/2024 12:30 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 11/06/2024 at 11:23 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: NEW HAVEN
FACILITY NUMBER: 365530037

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the administrator did not comply with the section cited above by conducting emergency drills quarterly which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/20/2024
Plan of Correction
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Administrator stated that he will train staff on regulation cited and submit proof of attendance sheet 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: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
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: NEW HAVEN
FACILITY NUMBER: 365530037
VISIT DATE: 11/06/2024
NARRATIVE
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Yards/Outside: One shaded patio, side gate with self-latching handle on the right side of the house that leads into the backyard, and attached garage. 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's and staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA observed that two staff did not have a health physical test completed. Deficiency issued. LPA reviewed 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. Medication was audited and appeared to be dispensed properly. LPA observed that the facility skipped a quarter on their emergency drills. Deficiency issued. Liability insurance, surety bond and emergency disaster plan were current and up to date.

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 Staff, Dinah Pasco.

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

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
LIC809 (FAS) - (06/04)
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