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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366409888
Report Date: 06/13/2024
Date Signed: 06/13/2024 01:21:04 PM

Document Has Been Signed on 06/13/2024 01:21 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:LIFETIME ADULT DAY CAREFACILITY NUMBER:
366409888
ADMINISTRATOR/
DIRECTOR:		JONES-ZAROUR, THERESAFACILITY TYPE:
775
ADDRESS:10871 CENTRAL AVETELEPHONE:
(909) 364-1676
CITY:ONTARIOSTATE: CAZIP CODE:
91762
CAPACITY: 30CENSUS: DATE:
06/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Assistant Director Amber Ann ArechigaTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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On 06/13/2024 at 09:30 AM, Licensing Program Analyst (LPA) Melody Brown arrived unannounced at the facility to conduct the required comprehensive annual inspection. LPA Brown was greeted by a staff at the reception area, LPA Brown introduced self and stated the purpose of the visit. Assistant Director Amber Ann Arechiga was informed of the visit and met with LPA Melody Brown.

LPA Brown completed a walkthrough of the facility, interview clients and staffs and review of records. The following were observed:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD), LPA Brown observed multiple clients attending the Day Program. There are no obstructions to indoor passageway and outdoor passageway of the Day Program. The facility is maintained at a comfortable temperature at 71 degrees Fahrenheit. LPA Brown inspected client classroom; they are equipped with required furniture such as: tables, storage space, chairs, and sufficient lighting. LPA Brown inspected client bathrooms; bathrooms were clean, and appliances were found functional. Hot water temperature tested at 123.8 degrees Fahrenheit. Deficiency will be issued. The facility is equipped with operational combined smoke detectors and carbon monoxide alarms. LPA Brown observed three (3) charged fire extinguishers, and first aid kit with first aid book.

Posters such as the personal rights, CCLD complaint poster, emergency disaster plan were posted in a common area. Sharps and chemicals were kept in secure cabinets inaccessible to clients. The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility. Overall, the facility is clean, and operates in safe conditions for clients in care.

***Continuation in LIC809C***

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2024
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
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: LIFETIME ADULT DAY CARE
FACILITY NUMBER: 366409888
VISIT DATE: 06/13/2024
NARRATIVE
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Records Review: LPA Brown reviewed client files for Admission Agreements, Needs and Services Plans (LIC625), Physician Report (LIC602) and current Individual Program Plan (IPP). LPA Brown observed that all files were complete. LPA also reviewed staff and Assistant Director's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with Tuberculosis (TB) Test result. Per LPA Brown records review, Staff #2 (S2) does not have criminal background clearance. LPA Brown cross reference Guardian database, it indicated “in process.” Deficiency will be issued. Also, LPA Brown observed the facility does not have a qualified Administrator, deficiency will be issued.

Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102, LIC421BG and Appeal Rights were discussed, and copies were provided to Assistant Director Amber Ann Arechiga.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 06/13/2024 01:21 PM - It Cannot Be Edited


Created By: Melody Brown On 06/13/2024 at 12:35 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: LIFETIME ADULT DAY CARE
FACILITY NUMBER: 366409888

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1522(c)(1)
General Provisions
(c)(1) Subsequent to initial licensure, a person specified in subdivision (b) who is not exempted from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification pursuant to subdivision (g) of this section or Section 1522.7 from the State Department of Social Services prior to employment, residence, or initial presence in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not obtaining a criminal record clearance for Staff #2 (S2) prior to employment which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2024
Plan of Correction
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Licensee removed S2 at the Day Program during the visit. Plan of Correction (POC) cleared.
Licensee stated to submit Signed Statement of Understanding on HSC 1522(c)(1) to LPA Brown on 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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 06/13/2024 01:21 PM - It Cannot Be Edited


Created By: Melody Brown On 06/13/2024 at 12:35 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: LIFETIME ADULT DAY CARE
FACILITY NUMBER: 366409888

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82064(a)(1)
Administrator -Qualifications and Duties
(a) All adult day programs shall have an administrator who meets either of the following requirements: (1) A baccalaureate degree in psychology, social work or a related human services field and a minimum of one year experience in the management of a human services delivery system, or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not having an administrator who meets the required qualifications of a baccalaureate degree in psychology, social work or a related human services field and a minimum of one year experience in the management of a human services delivery system which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2024
Plan of Correction
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Licensee stated to hire an Administrator that will meet the required qualifications and submit proof to LPA Brown on Plan of Correction (POC) due date.
Type B
Section Cited
CCR
82088(e)(1)
(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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 by not having the hot water between 105 degrees Fahrenheit to 120 degrees Fahrenheit ias evidenced of 123.8 degree F measured in clients common bathroom which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2024
Plan of Correction
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Licensee stated to adjust/regulate the hot water in client's bathroom between 105 degrees Fahrenheit to 120 degrees Fahrenheit and submit proof to LPA Brown on 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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2024


LIC809 (FAS) - (06/04)
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