365530097-8-22-2024-56-AS-BMAN-D8DQUC-20240822122830

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 365530097
Report Date: 08/22/2024
Date Signed: 08/22/2024 12:29:44 PM

Document Has Been Signed on 08/22/2024 12:29 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	NOLA HOMES II		FACILITY NUMBER:	365530097
ADMINISTRATOR:	WILSON, ASIA		FACILITY TYPE:	735
ADDRESS:	15921 NOTRE DAME ST		TELEPHONE:	(310) 658-4856
CITY:	FONTANA	STATE: CA	ZIP CODE:	92336
CAPACITY:	4	CENSUS: 1	DATE:	08/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Licensee/Administrator Asia Wilson		TIME COMPLETED:	12:35 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 08/22/2024 at 09:05 AM, Licensing Program Analysts (LPAs) Becky Mann and Melody Brown conducted an unannounced visit to the facility to conduct the required comprehensive annual inspection. LPAs Mann and Brown were greeted by a staff and gained access at the home. Licensee/Administrator Asia Wilson was contacted and arrived during the visit. LPAs Mann and Brown explained the purpose of the visit to Licensee/Administrator Wilson. The facility has four (4) bedrooms, three (3) bathrooms, kitchen, dining room, living room, attached garage, and backyard. The facility is vendorized by Inland Regional Center (IRC). LPAs Mann and Brown completed a walkthrough of the facility, review of records and medications audit. Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD), LPAs Mann and Brown observed no client during the visit as Licensee/Administrator Wilson reported to LPAs Mann and Brown that Client #1 (C1) is out in the community. There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 71 degrees Fahrenheit. LPAs Mann and Brown inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, chairs, and sufficient lighting. LPAs Mann and Brown inspected client bathrooms; bathrooms were clean, and appliances were found functional. Water temperatures tested at 107 degrees Fahrenheit. The facility is equipped with operational combined smoke detectors and carbon monoxide detectors, charged fire extinguishers, and first aid kit with first aid book. In addition, LPAs Mann and Brown observed no non-slip mat on clients bathroom. Deficiency will be issued. Posters such as the personal rights, CCLD complaint poster, and emergency disaster plan were posted in a common area. Client medications were kept in secure cabinets inaccessible to clients. LPAs Mann and Brown observed night lights at the hallway leading to clients' shared bathrooms. The facility had emergency kits, emergency food and water. *Continuation on LIC 809C*

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Becky Mann	TELEPHONE: 951-248-0306
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: NOLA HOMES II	FACILITY NUMBER: 365530097
	VISIT DATE: 08/22/2024

NARRATIVE

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There are no firearms and ammunition in the facility.

Yards/Outside: One shaded patio, one (1) side gate with self-latching handle on the left side of the house that leads into the backyard, attached two (2) car garage observed. All outdoor pathways were free of obstructions.

Food Service: LPAs Mann and Brown observed two (2) day(s) supply of perishable food and seven (7) day(s) supply of non-perishables food and snacks. Dishes, cups, and utensils were stored properly.

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

Record Review: LPAs Mann and Brown reviewed one (1) client files for admission agreements, medical assessments/physician reports, and Individual Program Plan (IPP). LPAs Mann and Brown observed files reviewed were complete. LPAs Mann and Brown also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test result. LPAs Mann and Brown observed that files reviewed were complete.

LPAs Mann and Brown audited one (1) client medications and no issues were observed.

Deficiency was cited during this visit. An exit interview was conducted where this report LIC809, LIC809D, and Appeal Rights were discussed, and copies were provided to Licensee/Administrator Asia Wilson.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Becky Mann	TELEPHONE: 951-248-0306
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/22/2024 12:29 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: NOLA HOMES II	FACILITY NUMBER: 365530097
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(b)(1)

Building and Grounds

(b) All clients shall be protected against hazards within the facility through provision of the following: (1) Protective devices including but not limited to nonslip material on rugs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above by not ensuring that there is a non-slip mat on client's bathroom which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/30/2024
	Plan of Correction
1 2 3 4	Licensee stated to obtain/purchase non-slip mat and submit proof to LPA Mann on Plan of Correction (POC) due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Becky Mann	TELEPHONE: 951-248-0306
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024

LIC809 (FAS) - (06/04)

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