<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366412344
Report Date: 06/01/2022
Date Signed: 06/01/2022 10:52:35 AM

Document Has Been Signed on 06/01/2022 10:52 AM - 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:TOMORROW'S WORLD-N.NORTHSTARFACILITY NUMBER:
366412344
ADMINISTRATOR:VICKERS, DEBBIEFACILITY TYPE:
735
ADDRESS:1334 N. NORTHSTAR ST.TELEPHONE:
(909) 877-5783
CITY:COLTONSTATE: CAZIP CODE:
92324
CAPACITY: 6CENSUS: 5DATE:
06/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:02 AM
MET WITH:Debbie Vickers - LicenseeTIME COMPLETED:
09:32 AM
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
Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to conduct a required annual inspection with an emphasis on infection control. LPA identified herself to licensee Debbie Vickers. Licensee verified that the facility currently has no active and/or suspected COVID-19 cases.

During the inspection, LPA Bueno interviewed Licensee regarding the facility's infection control measures and inspected the facility for regulatory compliance. LPA observed appropriate postings in the facility, including COVID-19 symptoms and infection control postings, which were in accordance with the Department's guidelines. LPA observed that the facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a 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 and that staff are trained in the facility's infection control measures. The facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolation, and properly caring for clients with COVID-19 positive results and/or exposures. The facility also has a plan in place to monitor residents regularly for any changes in condition and to notify the resident's physician and emergency personnel in the event the resident presents any COVID-19 symptoms.

During the inspection, LPA observed that 2 of 3 bedrooms did not have chairs or night stands. This poses a potential health, safety, or personal right risk to clients in care. Refer to LIC809D for deficiency cited. Technical advisories were provided to maintain a logs for facility visitors and daily temperature and Covid-19 symptom log, and to remind staff to wear face coverings.

An exit interview was conducted where this report, LIC809D, LIC9102, and appeal rights were discussed with and copies provided to Debie Vickers at the conclusion of the inspection.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2022
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
Document Has Been Signed on 06/01/2022 10:52 AM - It Cannot Be Edited


Created By: Anna Bueno On 06/01/2022 at 09:02 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
, CA 92507

FACILITY NAME: TOMORROW'S WORLD-N.NORTHSTAR
FACILITY NUMBER: 366412344

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(c)(2)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (2) Bedroom furniture including, in addition to (c)(1) above, for each client, a chair, a night stand, and a lamp or lights necessary for reading.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observation and staff and clients interviews, the Licensee did not comply with the section cited above as 2 of 3 bedrooms did not have chairs and/or night stands which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/05/2022
Plan of Correction
1
2
3
4
Licensee shall provide proof of required furniture all client bedrooms no later than end of 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
LICENSING EVALUATOR NAME:Anna Bueno
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2022


LIC809 (FAS) - (06/04)
Page: 6 of 6