366412235-8-28-2024-56-AS-BMAN-D8KV93-20240828161340

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366412235
Report Date: 08/28/2024
Date Signed: 08/28/2024 04:14:30 PM

Document Has Been Signed on 08/28/2024 04:14 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	D'VINE HOME		FACILITY NUMBER:	366412235
ADMINISTRATOR:	CONCEPCION PANOPIO		FACILITY TYPE:	740
ADDRESS:	16123 VINE STREET		TELEPHONE:	(760) 981-4595
CITY:	HESPERIA	STATE: CA	ZIP CODE:	92345
CAPACITY:	10	CENSUS: 7	DATE:	08/28/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:05 AM
MET WITH:	Flordeliza Salvatierra		TIME COMPLETED:	04:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 08/28/24, Licensing Program Analyst (LPA) Becky Mann and Magda Malcore arrived unannounced to conduct the required annual visit to the facility. LPAs met with Flordeliza Salvatierra and introduced and stated purpose of the visit. LPAs were informed that there are 7 clients who are in program. The facility has 6 bedrooms, 2 bathrooms, kitchen, dining area, living room, backyard, and attached garage. LPAs completed a walk through of the facility, review of records, and medication audit. 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 76 degrees fahrenheit. LPAs inspected clients' bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPAs inspected clients' bathrooms; bathrooms were clean and appliances were found functional. LPAs observed no non-slip mats in the bathroom. Water temperatures tested at 109 degrees fahrenheit. The facility is equipped with operational carbon monoxide alarms, charged fire extinguisher and first aid kit. Posters such as; the personal rights, facility license and CCL complaint poster were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept locked and inaccessible to clients. There were 2 non-operable smoke detectors.There was a designated storage space for client/staff files. Medications was observed locked and inaccessible to clients. 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. Facility did not have a first aid manual. 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.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Becky Mann	TELEPHONE: 951-248-0306
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024

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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Document Has Been Signed on 08/28/2024 04:14 PM - It Cannot Be Edited

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: D'VINE HOME	FACILITY NUMBER: 366412235
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(c)(2)

Incidental Medical and Dental Care Services

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by checking the MAR. The licensee did not log the client's medication for 8/28 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/29/2024
	Plan of Correction
1 2 3 4	Licensee stated that she has agreed to send pictures of the up-to-date MARs log by Plan of Correction (POC) date

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Becky Mann	TELEPHONE: 951-248-0306
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024

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: D'VINE HOME	FACILITY NUMBER: 366412235
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(e)(5)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by not having non-skid mats in the bathrooms which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/11/2024
	Plan of Correction
1 2 3 4	Licensee stated that she will provide pictures of non-skid mats in clients bathrooms.

Type B

Section Cited

CCR

87411(c)(1)

Personnel Requirements - General

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by the staff not having up-to-date First Aid/CPR certifications which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/11/2024
	Plan of Correction
1 2 3 4	Licensee stated that she will provide pictures of the First AId/CPR certifications.

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	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Becky Mann	TELEPHONE: 951-248-0306
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/28/2024 04:14 PM - It Cannot Be Edited

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: D'VINE HOME	FACILITY NUMBER: 366412235
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(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 residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by not having fire and/or earthquake drill logged which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/11/2024
	Plan of Correction
1 2 3 4	Licensee stated that she will conduct an fire and/or earthquake drill.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Becky Mann	TELEPHONE: 951-248-0306
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024

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: D'VINE HOME	FACILITY NUMBER: 366412235
	VISIT DATE: 08/28/2024

NARRATIVE

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Yards/Outside: One shaded patio, 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 reviewed administrator and DSP files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. There was 3 staff who did not have up-to-date First Aid/CPR certifications. LPA reviewed 6 client files for admission agreements, updated physician reports, and needs and services plans. Medication was audited and did not match with MARs. LPA reviewed facility's file for fire drills, infection control plan, and emergency disaster plan. LPAs observed the facility did not have fire and/or earthquake drill logged.

An exit interview was conducted where the reports of LIC809, LIC809C, and LIC809D were discussed and copies were provided to Flordeliza Salvatierra.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Becky Mann	TELEPHONE: 951-248-0306
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/28/2024 04:14 PM - It Cannot Be Edited

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: D'VINE HOME	FACILITY NUMBER: 366412235
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87203

All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshall for the protection of life and property against fire and panic. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above by not having 2 operable fire detectors which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/29/2024
	Plan of Correction
1 2 3 4	Licensee stated that she will send a video of the smoke detectors working properly.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Becky Mann	TELEPHONE: 951-248-0306
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024

LIC809 (FAS) - (06/04)

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