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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366400553
Report Date: 09/13/2023
Date Signed: 09/13/2023 10:37:53 AM

Document Has Been Signed on 09/13/2023 10:37 AM - 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:MOJAVE NARROWS RANCH HOMEFACILITY NUMBER:
366400553
ADMINISTRATOR:ENTZ, BRIANFACILITY TYPE:
735
ADDRESS:14599 RIVERSIDE DRIVETELEPHONE:
(760) 242-6945
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY: 6CENSUS: 3DATE:
09/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Peggy Ames-DSPTIME COMPLETED:
10:42 AM
NARRATIVE
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On 09/13/23, Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with DSP, Peggy Ames, introduced self and stated purpose of the visit.

The facility has 6 bedrooms, 4 bathrooms, kitchen, dining room, living room, family room, laundry room, attached garage, backyard, back house and shed. The facility is vendorized by Inland Regional Center. LPA completed a walk through of facility and review of medication and 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 comfortable temperature of 77 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, emergency disaster plan were posted in a common area. LPA observed the emergency disaster plan outdated and not reviewed since 11/11/20. Deficiency issued. Cleaning supplies, toxins, sharps, medication and other dangerous items were kept in secure cabinets inaccessible to clients. Clients/staff files were observed inside the staff's bedroom made inaccessible to clients. The facility had emergency kits, emergency food and water in the garage. There are no pools, bodies of water, firearms or ammunition. 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 for number of clients in care. Facility has a wide variety of food available for clients. Dishes, cups, and utensils were also stored properly.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2023
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 09/13/2023 10:37 AM - It Cannot Be Edited


Created By: Michelle Echeverria On 09/13/2023 at 10:07 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: MOJAVE NARROWS RANCH HOME
FACILITY NUMBER: 366400553

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(d)(6)
Infection Control Requirements
(d) When an emergency, as defined in Government Code section 8558, or federal emergency for a contagious disease is proclaimed or declared, the licensee shall develop an Emergency Infection Control Plan that includes infection control measures that are not already addressed in the Infection Control Plan as specified in subsection (c), to prevent, contain, and mitigate the associated contagious disease.  (6) The Emergency Infection Control Plan shall be reviewed and updated as necessary or whenever new infection control measures are recommended by the federal, state or local government public health authorities, or as determined by the Department, until the proclaimed or declared state of emergency is no longer in effect.  Any updates to the plan shall be made available to staff, clients and if applicable, each client's representative, and submitted to the Department. 

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 in reviewing and updating the Infection Control Plan which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2023
Plan of Correction
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Administrator stated that he will review and update the Infection Control Plan and submit a copy 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: 09/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/13/2023 10:37 AM - It Cannot Be Edited


Created By: Michelle Echeverria On 09/13/2023 at 10:07 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: MOJAVE NARROWS RANCH HOME
FACILITY NUMBER: 366400553

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2023

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 and record review, the administrator did not comply with the section cited above in conducting a drill for the last quarter since the last drill performed on 02/26/23 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2023
Plan of Correction
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Admininstrator stated that he will conduct a training with staff going over regulation HSC 1565(c) and submit proof of meeting to LPA via email by POC due date.
Type B
Section Cited
HSC
1565(d)
Other Provisions
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee, administrator, or regulated individual shall sign and date the documentation to indicate that the plan has been reviewed and updated as necessary.

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 reviewing the Emergency Disaster Plan annually which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2023
Plan of Correction
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Administrator stated that he will review the Emergency Disaster Plan 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: 09/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2023


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: MOJAVE NARROWS RANCH HOME
FACILITY NUMBER: 366400553
VISIT DATE: 09/13/2023
NARRATIVE
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Yards/Outside: One shaded patio, a side gate with self-latching handle on the right side of the house that leads into the backyard, a back house and shed used for storage. 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 1 client file for admission agreements, updated physician reports, and needs and services plans. LPA reviewed the administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. The facility last conducted a fire drill in 02/26/23. Deficiency issued for missing last quarter. LPA observed that the Infection Control Plan has not been reviewed and updated since 07/13/21. Deficiency issued. Medication was audited at random and appeared to be dispensed appropriately according to regulations.

Three 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 DSP, Peggy Ames.

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

DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023
LIC809 (FAS) - (06/04)
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