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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366408353
Report Date: 09/26/2024
Date Signed: 09/26/2024 12:41:10 PM

Document Has Been Signed on 09/26/2024 12:41 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:JP'S RESIDENTIAL CAREFACILITY NUMBER:
366408353
ADMINISTRATOR/
DIRECTOR:		PIERRE, YVONNEFACILITY TYPE:
735
ADDRESS:922 W. MESA DRIVETELEPHONE:
(909) 875-6147
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY: 2CENSUS: 1DATE:
09/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Yvonne Pierre, Licensee and AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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On 09/26/24, Licensing Program Analysts (LPAs) Becky Mann and Melody Brown arrived unannounced to conduct the required comprehensive annual inspection to the facility. LPAs Mann and Brown met with Licensee/Administrator Yvonne Pierre and introduced selves and stated purpose of the visit.

The facility has five (5) bedrooms, three (3) bathrooms, kitchen, dining area, living room, family room, backyard, and attached garage. LPAs Mann and Brown completed a walk through of facility, review of records, medication audit.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 74 degrees Fahrenheit. LPAs Mann and Brown inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPAs observed that there is no night light maintained in hallways and passages to nonprivate bathrooms. Deficiency will be issued. LPAs Mann and Brown inspected client bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 109 degrees Fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, charged fire extinguisher and first aid kit wit First Aid book. LPAs observed one (1) bottle of bleach under sink, not locked and accessible to client in care. Deficiency will be issued. There was a designated storage space for client/staff files. Client medications was observed locked and inaccessible to client. However, LPAs observed one (1) bottle of Over-the-Counter (OTC) medicine of Staff #1 (S1) in the kitchen cabinet, not locked and accessible to client in care. Deficiency will be issued. There is no firearms, ammunition, swimming pool or bodies of water in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care.
***Continuation LIC 809C***
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Becky Mann
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2024
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: JP'S RESIDENTIAL CARE
FACILITY NUMBER: 366408353
VISIT DATE: 09/26/2024
NARRATIVE
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Posters such as; the personal rights, facility license were posted in a common area. However. LPAs observed that the facility does not have the required CCLD Complaint Poster. Technical Violation will be issued. Also, LPAs observed two (2) window screens in disrepair. Technical Violation will be issued.

Food Service: Non-perishable and perishable food supply is sufficient. Facility has a wide variety of food available. Dishes, cups, and utensils were also stored properly

Yards/Outside: Side gate with self-latching handle on the left side of the house that leads into the backyard. 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: LPAs observed that Licensee did not develop the required Infection Control Plan. Deficiency will be issued. In addition, LPA reviewed administrator files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings, tuberculosis (TB) test with TB test result. LPAs observed that files reviewed were complete. LPA reviewed one (1) client files for admission agreements, updated physician reports/medical assessment, Individual Program Plan (IPP) and centrally stored medication list. LPAs observed no issue.

Client #1 (C1) medications was audited and LPAs observed no issue.. LPA reviewed facility's file for fire drills, and emergency disaster plan. No issues observed.

Deficiencies were cited per Title 22, Division 6 of California Code of Regulation (CCR) during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102 and Appeal Rights were discussed and copies were provided to Yvonne Pierre, Licensee/Administrator.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Becky Mann
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 09/26/2024 12:41 PM - It Cannot Be Edited


Created By: Becky Mann On 09/26/2024 at 11:27 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: JP'S RESIDENTIAL CARE
FACILITY NUMBER: 366408353

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 not ensuring that the one (1) bottle of bleach observed under the kitchen sink was locked and not accessible to client in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/27/2024
Plan of Correction
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Licensee immediately lock the observed on (1) bottle of bleach during the visit. Plan of Correction (POC) cleared.
Type A
Section Cited
CCR
80087(h)
Building and Grounds
(h) Medicines shall be stored as specified in Section 80075(m) and (n) and separately from other items specified in Section 80087(g) above.

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 not ensuring that the observed one (1) bottle of Over-the-Counter (OTC) medication of Staff #1 (S1) in the kitchen cabinet, was locked and not accessible to client in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/27/2024
Plan of Correction
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Licensee immediately lock the observed one (1) bottle of OTC medication of S1 during the visit. POC cleared.
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:Becky Mann
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 09/26/2024 12:41 PM - It Cannot Be Edited


Created By: Becky Mann On 09/26/2024 at 11:27 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: JP'S RESIDENTIAL CARE
FACILITY NUMBER: 366408353

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above by not developing the required Infection Control Plan which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2024
Plan of Correction
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Licensee stated to submit a copy of the required Infection Control Plan to LPA Mann on Plan of Correction (POC) due date.
Type B
Section Cited
CCR
85088(e)(2)
Fixtures, Furniture, Equipment, and Supplies
(e) Emergency lighting, which shall include at a minimum working flashlights or other battery-powered lighting, shall be maintained and readily available in areas accessible to clients and staff. (2) Night lights shall be maintained in hallways and passages to nonprivate bathrooms.

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 not maintaining the required night lights in hallways and passages to nonprivate bathrooms which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2024
Plan of Correction
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Licensee showed proof of purchase of night lights during the visit. Plan of Correction (POC) cleared.
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:Becky Mann
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2024


LIC809 (FAS) - (06/04)
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