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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366406754
Report Date: 08/22/2023
Date Signed: 08/22/2023 02:58:26 PM

Document Has Been Signed on 08/22/2023 02:58 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:WINTER PLACEFACILITY NUMBER:
366406754
ADMINISTRATOR:NEAL, DAVIDFACILITY TYPE:
735
ADDRESS:11375 WINTER PLACETELEPHONE:
(760) 246-6465
CITY:ADELANTOSTATE: CAZIP CODE:
92301
CAPACITY: 8CENSUS: 8DATE:
08/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:58 AM
MET WITH:Myra Williams- House ManagerTIME COMPLETED:
03:06 PM
NARRATIVE
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On 08/22/23, Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with house manager, Myra Williams, and introduced self and stated purpose of the visit.

The facility has 5 client bedrooms, 1 staff bedroom, 3 bathrooms, kitchen, dining area, living room, laundry room, attached garage, and backyard. LPA completed a walk through of the facility and review of 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 105.2 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, first aid kit and charged fire extinguishers. Posters such as; the personal rights, house rules, facility sketch, and emergency disaster plan were posted in a common area. LPA observed the emergency disaster plan not reviewed since 11/28/20. Deficiency issued. Cleaning supplies, toxins, sharps, and other dangerous items were kept in secure cabinets inaccessible to clients. There was a designated storage space for clients/staff files. Medications were observed to be inaccessible inside a locked closet. The facility had emergency kits, food and water inside the garage. LPA observed the facility to not be clean, in good repair, and operating in safe conditions for clients in care due to dusty stained floors and windows along with insufficient broken chairs in the dining table. Deficiency issued.

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: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2023
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 08/22/2023 02:58 PM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Michelle Echeverria On 08/22/2023 at 01:55 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: WINTER PLACE
FACILITY NUMBER: 366406754

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(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 in maintaining a clean, safe, sanitary and in good repair facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2023
Plan of Correction
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Licensee states that the floors and windows will be clean and dust off. Licensee states that additional safe and sturdy chairs will be replaced in dining table. Licensee will submit pictures to LPA via email by POC due date.
Under Appeal
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in providing original first aid and CPR certification without alterations which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2023
Plan of Correction
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Licensee states that she will provide original first aid and CPR certifications for each staff 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: 08/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/22/2023 02:58 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 08/22/2023 at 01:55 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: WINTER PLACE
FACILITY NUMBER: 366406754

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2023

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 interview, the licensee did not comply with the section cited above in conducting a drill for each shift varying from quarter to quarter which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2023
Plan of Correction
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Licensee states that she will train all staff with regulation HSC 1565(c) and submit proof of training by POC due date to LPA via email.
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, the licensee 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: 08/29/2023
Plan of Correction
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Licensee states that she will review the emergency disaster plan annually and train the required staff. Licensee states that she will submit a copy of the reviewed emergency disaster plan 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: 08/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2023


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: WINTER PLACE
FACILITY NUMBER: 366406754
VISIT DATE: 08/22/2023
NARRATIVE
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Yards/Outside: One shaded patio, a side gate with self-latching handle on the left side of the house that leads into the backyard.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department. House manager resides in the home.

Record Review: LPA reviewed 4 client files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed 2 staff and administrator's file for First Aid/CPR certification, criminal record clearance, and health screenings. LPA observed a log for drills performed by the same staff member at the same time and date during the beginning of each month (same shift without variation). Deficiency issued. LPA observed that all staff certifications for first aid and CPR certification have been altered due to change of font per staff name, same certificate number and issue/expiration dates. 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 house manager, Myra Williams.

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

DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023
LIC809 (FAS) - (06/04)
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