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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366406754
Report Date: 06/10/2022
Date Signed: 06/10/2022 01:44:43 PM

Document Has Been Signed on 06/10/2022 01:44 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:WINTER PLACEFACILITY NUMBER:
366406754
ADMINISTRATOR:NEAL, DAVIDFACILITY TYPE:
735
ADDRESS:11375 WINTER PLACETELEPHONE:
(760) 246-6465
CITY:ADELANTOSTATE: CAZIP CODE:
92301
CAPACITY: 8CENSUS: 8DATE:
06/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:58 AM
MET WITH:Myra Williams, House managerTIME COMPLETED:
01:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Rayshaun Nickolas conducted an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. LPA Nickolas arrived and met with House manager, Williams. LPA Nickolas was asked to sign-in and provide temperature reading upon arrival. The house manager confirmed that there are currently no cases/exposures of COVID-19 within the facility.

During the inspection, LPA Nickolas conducted a tour of the facility and made observations pertaining to the facility's infection control measures and other health and safety concerns. LPA Nickolas observed appropriate postings throughout the facility, including hand-washing etiquette, face coverings, and COVID-19 symptoms postings. The facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a supply of Personal Protective Equipment (PPE). LPA observed that the facility staff wearing face coverings. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the facility's infection control measures. The facility has a plan in place which follows Community Care Licensing Division (CCLD) guidelines for COVID-19 testing, isolating/quarantining residents, and properly caring for residents with COVID-19 positive results and/or exposures. The facility also has a plan in place to monitor residents regularly for any changes in condition and to subsequently notify the resident's physician and emergency personnel in the event the resident presents any COVID-19 symptoms.

LPA observed a resident's insulin medication centrally stored in the refrigerator accessible to all residents in care. LPA observed an inadequate supply of linens to permit changing at least once a week or more often if necessary. LPA observed an inadequate supply of towels and washcloths. LPA observed all bedrooms without chairs and lighting necessary for reading.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE: DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/10/2022
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: WINTER PLACE
FACILITY NUMBER: 366406754
VISIT DATE: 06/10/2022
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LPA observed a screw sticking out of the gate and loose sections in the fence. Based on observations made during today’s inspection, five deficiencies was cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted and a copy of this report, LIC 809D, and Appeal Rights were given to the House manager
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 06/10/2022 01:44 PM - It Cannot Be Edited


Created By: Rayshaun Nickolas On 06/10/2022 at 12:48 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
, CA 92507

FACILITY NAME: WINTER PLACE
FACILITY NUMBER: 366406754

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(1)
80075 Health Related Services (k)(1)
(k) The following requirements shall apply to medications which are centrally stored:
(1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in storing resident's insulin medication in the refrigerator with food accessible to all residents. Which poses an immediate health and safety risk to persons in care.
POC Due Date: 06/11/2022
Plan of Correction
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Licensee shall purchase and store medication in a medicine lock box in the refrigerator. Licensee shall submit proof of correction to LPA on 06/11/2022.
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:Karen Clemons
LICENSING EVALUATOR NAME:Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2022


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 06/10/2022 01:44 PM - It Cannot Be Edited


Created By: Rayshaun Nickolas On 06/10/2022 at 12:56 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
, CA 92507

FACILITY NAME: WINTER PLACE
FACILITY NUMBER: 366406754

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
80087 Buildings and Grounds (a)
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above by allowing the fence that surrounds the property to be loose and the gate to have exposed screws. Which poses a potential health and safety risk to persons in care.
POC Due Date: 07/15/2022
Plan of Correction
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Licensee shall repair gate and fence. Licensee shall submit proof of correction to LPA on 07/15/2022 by the closure of business.
Type B
Section Cited
CCR
85088 (4)(A)&(B)
85088 Fixtures, Furniture, Equipment and Supplies (4)(A)&(B)
A) The quantity of linen provided shall permit changing the linen at least once each week or more often when necessary to ensure that clean linen is in use by clients at all times.
(B) The use of common towels and washcloths shall be prohibited.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in not providing enough linen that permits changing the linen at least once each week or more often when necessary. Licensee did not ensure adequate supplies of towels and washclothes. Which poses a potential health and safety risk to persons in care.
POC Due Date: 06/22/2022
Plan of Correction
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Licensee shall purchase and store an adequate supply of linen that permits changing of linen at least once each week or more often when necessary for residents at the facility. Licensee shall purchase and store an adquate supply of towels and washcloths for residents at the facility. Licensee shall submit proof of correction to LPA on 06/22/2022 by the closure business.
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:Karen Clemons
LICENSING EVALUATOR NAME:Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2022


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 06/10/2022 01:44 PM - It Cannot Be Edited


Created By: Rayshaun Nickolas On 06/10/2022 at 01:12 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
, CA 92507

FACILITY NAME: WINTER PLACE
FACILITY NUMBER: 366406754

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(C)(2)
85088 Fixtures, Furniture, Equipment and Supplies (C)(2)
(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 licensee did not comply with the section cited above in not providing residents with chairs in their rooms and adequate lighting necessary for reading. Which poses a potential health and safety risk to persons in care.
POC Due Date: 06/22/2022
Plan of Correction
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Licensee shall provide chairs and adequate lighing necessary for reading in each bedroom. Licensee shall submit proof of correction to LPA on 06/22/2022 by the closure of business.
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:Karen Clemons
LICENSING EVALUATOR NAME:Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2022


LIC809 (FAS) - (06/04)
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