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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366411355
Report Date: 01/20/2022
Date Signed: 01/20/2022 06:14:25 PM

Document Has Been Signed on 01/20/2022 06:14 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
RIVERSIDE, CA 92507
FACILITY NAME:PALMETTO FAMILY HOMEFACILITY NUMBER:
366411355
ADMINISTRATOR:CARDEN, LORIFACILITY TYPE:
735
ADDRESS:9169 PALMETTO AVENUETELEPHONE:
(909) 854-5398
CITY:FONTANASTATE: CAZIP CODE:
92335
CAPACITY: 6CENSUS: 6DATE:
01/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:House Manager Laporsha GrantTIME COMPLETED:
06:30 PM
NARRATIVE
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Licensing Program Analyst (LPAs) Melody Brown made an unannounced visit to the facility to conduct an annual inspection, with emphasis on infection control. LPA was greeted and granted entrance by caregiver Ciara Johnson and LPA Brown explained the purpose of today's visit. House Manager Laporsha Grant was contacted and informed of LPA Brown’s arrival. Caregiver Lanisha Jenkins arrived for the PM Shift while LPA Brown was at the facility. House Manager Laporsha Grant arrived and accompanied LPA Brown on a tour of the inside and outside of the facility.

During today’s visit, LPA Brown made observation pertaining to the facility’s current infection control measures. LPA Brown observed a screening area, proper signages throughout the facility, sufficient hand hygiene supplies, cleaning supplies, and a sufficient supply of Personal Protective Equipment (PPE). The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, cleaning and disinfection are in adequate quantities, and that staff are trained in overall infection control.

The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and resident for COVID-19, when and how to isolate/quarantine client, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas/surfaces. The facility also has a plan in place to monitor resident regularly for any changes in condition and to subsequently notify the client's physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses.



LPAs Brown inquired on the facility’s Covid-19 training for facility staff and confirmed that staff have been trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing of PPE. LPA Brown inquired as to if staff have been fit tested for N95 masks and House Manager Grant reported to LPA Brown that at this time staff have not been fit tested. ***Continuation on LIC 809-C***
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 01/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/20/2022
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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Document Has Been Signed on 01/20/2022 06:14 PM - It Cannot Be Edited


Created By: Melody Brown On 01/20/2022 at 05:07 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: PALMETTO FAMILY HOME
FACILITY NUMBER: 366411355

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(a)


This requirement is not met as evidenced by:
Deficient Practice Statement
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80019 Criminal Record Clearance (a) The Department shall conduct a criminal record review of all individuals specified in Health and Safety Code 1522(b) and shall have the authority to approve... Based on records review and iinterview, the licensee did not comply with the section cited above by allowing R1 to work at the facility without criminal record clearance which poses an immediate health and safety risk to persons in care.
POC Due Date: 01/20/2022
Plan of Correction
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Licensee must remove R1 at the facility until criminal clearance record has been cleared. R1 was removed at the facility today, POC cleared.
Type A
Section Cited
HSC
130


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and records review, the licensee did not comply with the section cited above because Licensee did not provide all staff who are working with Covid 19 positive residents with fit testing for N95 respirators. This practice has a Health and Safety impact that includes but is not limited to personal rights, buildings and grounds and responsibility for providing care and supervision which poses an immediate health and safety risk to persons in care.
POC Due Date: 01/21/2022
Plan of Correction
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Licensee will submit inquiries and appointmade made for N95 Fit test by POC due date to LPA.
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: 01/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/20/2022


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
RIVERSIDE, CA 92507
FACILITY NAME: PALMETTO FAMILY HOME
FACILITY NUMBER: 366411355
VISIT DATE: 01/20/2022
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***Continuation from LIC 809***

LPA Brown will be issuing a deficiency for staff not being fit tested for N95 masks due to the facility having COVID-19 positive resident recently, and N95 masks needs to be worn when a resident is COVID-19 positive or under observation while awaiting test results.

Additionally, House Manager Laporsha Grant reported that all residents and staff have been vaccinated and are practicing other COVID-19 precautions, which minimize the risk of them contracting COVID-19. LPA Brown will be providing House Manager Grant with the information for Provider Information Notice (PIN) PIN-21-10-ASC which contains resources for getting staff fit tested for N95 masks.



In addition, during the tour LPA Brown noticed that one of the resident bedrooms has a crack on the wall and the blinds were in disrepair and needs to be addressed. LPA Brown will be issuing a technical violation for this issue.

In the process of conducting the annual inspection, LPA Brown discovered that the facility allowed one (1) caregiver, Staff 1 (S1) to work at this facility without fingerprint clearance. It appears that S1 have been allowed to work at the facility. Although House Manager reported that S1 was sent to get fingerprint cleared, there is no proof provided that S1 was cleared to be allowed to work at the facility. Therefore, this facility will be cited for civil penalties.

An exit interview was conducted with House Manager Laporsha Grant and a copy of this report (LIC809), LIC 809-D, LIC9102-TV, LIC421BG and Appeal Rights were provided.

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

DATE: 01/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022
LIC809 (FAS) - (06/04)
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