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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366405731
Report Date: 10/17/2023
Date Signed: 10/17/2023 03:54:40 PM

Document Has Been Signed on 10/17/2023 03:54 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:GERONA ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
366405731
ADMINISTRATOR:JONATHAN B. GERONAFACILITY TYPE:
735
ADDRESS:14519 PONY TRAIL ROADTELEPHONE:
(760) 955-8567
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 6CENSUS: 6DATE:
10/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:04 PM
MET WITH:Chenier Gerona- StaffTIME COMPLETED:
04:05 PM
NARRATIVE
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On 10/17/23, Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with Staff Chenier Gerona introduced self and stated purpose of the visit.

The facility has 4 bedrooms, 3 bathrooms, kitchen, dining room, living room, family room, laundry room, attached garage, and backyard. LPA completed a walk through of the facility, review of records, 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 75 degrees fahrenheit. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA observed missing chairs in shared bedrooms. Deficiency issued. LPA observed the clients bedroom downstairs to be restricted to access to the kitchen and bathroom due to the lock door knob placed on the outside. Deficiency issued. LPA inspected client bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 106.0 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, charged fire extinguisher, and first aid kit. Posters such as; the personal rights, CCL complaint poster, emergency disaster plan were not posted in a common area. Deficiency issued. LPA observed the emergency disaster plan outdated and last reviewed on 05/22/06. Deficiency issued. Chemicals, toxins, sharps, medications and other dangerous items were kept in secure cabinets inaccessible to clients. Clients/Staff files and P&I were observed locked and made inaccessible. There are no firearms and ammunition in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care.

Yards/Outside: One shaded patio, a side gate with self-latching handle on the left and right side of the house that leads into the backyard. All outdoor pathways were free of obstructions.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2023
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 6
Document Has Been Signed on 10/17/2023 03:54 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 10/17/2023 at 03:08 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: GERONA ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 366405731

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(c)(2)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (2) Bedroom furniture including, in addition to (c)(1) above, for each client, a chair, a night stand, and a lamp or lights necessary for reading.

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 in providing a chair for each client in their bedroom which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/24/2023
Plan of Correction
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Administrator stated that he will purchase the (3) missing chairs for clients. Administrator stated that he provide a copy of receipt and picture of chairs to LPA via email by POC due date.
Type B
Section Cited
CCR
80020(c)
Fire Clearance
(c) A licensee of an Adult Residential Facility or Group Home utilizing secured perimeters shall conduct fire and earthquake drills pursuant to Health and Safety Code section 1531.15(h).

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 fire and earthquake drills which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/24/2023
Plan of Correction
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Administrator stated that he will conduct and specify type of drill and provide 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: 10/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2023


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 10/17/2023 03:54 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 10/17/2023 at 03:08 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: GERONA ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 366405731

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)
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:

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 providing a complete personnel record for staff which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/24/2023
Plan of Correction
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Administrator stated that he will have staff complete personnel record and submit proof to LPA via email by POC due date.
Type B
Section Cited
CCR
80072(a)(2)
Personal Rights
(a) Except for children's residential facilities, each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.

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 violating the clients personal rights by restricting access to kitchen and bathroom which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/24/2023
Plan of Correction
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Administrator stated that he will remove the lock door knob on laundry-kitchen door and replace it with a non-lock door knob. Administrator stated that he will submit a picture via email 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: 10/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2023


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 10/17/2023 03:54 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 10/17/2023 at 03:08 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: GERONA ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 366405731

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80072(e)
Personal Rights
(e) The information specified in (b) above including the visiting policy as stated in the admissions agreement shall be prominently posted in areas accessible to clients and their visitors.

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 in posting CCL complaint poster, personal rights, visiting policy, and emergency disaster plan in a common area which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/24/2023
Plan of Correction
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Administrator stated that he will post CCL complaint poster, personal rights, visiting policy, and emergency disaster plan in a common area and provide proof to LPA via email by POC due date.
Type B
Section Cited
CCR
80070(b)
Client Records
(b) Each record must contain information including, but not limited to, the following:

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 providing complete records for client which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/24/2023
Plan of Correction
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Administrator stated that he will complete client records 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: 10/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2023


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 10/17/2023 03:54 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 10/17/2023 at 03:08 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: GERONA ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 366405731

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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/updating the emergency disaster plan which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/24/2023
Plan of Correction
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Administrator stated that he will review/update the emergency disaster plan annually 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: 10/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2023


LIC809 (FAS) - (06/04)
Page: 5 of 6
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: GERONA ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 366405731
VISIT DATE: 10/17/2023
NARRATIVE
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Food Service: LPA observed 2 days of perishables and 7 days non-perishables food. Facility has a variety of food available. 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: LPA reviewed (3) client files for admission agreements, updated physician reports, and needs and services plans. LPA observed incomplete records for one client. Deficiency issued. LPA also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA observed missing records for one staff. Deficiency issued. P& I was audited and matched with record. LPA observed the last disaster drill conducted on 03/21/23 with no specification type. Deficiency issued.

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, Chenier Gerona.

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

DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023
LIC809 (FAS) - (06/04)
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