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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366412436
Report Date: 03/14/2024
Date Signed: 03/14/2024 04:28:13 PM


Document Has Been Signed on 03/14/2024 04:28 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:SEEGAL RESIDENTIAL CAREFACILITY NUMBER:
366412436
ADMINISTRATOR:JULIET SEEFACILITY TYPE:
740
ADDRESS:12727 HICKORY AVETELEPHONE:
(760) 951-3575
CITY:VICTORVILLESTATE: CAZIP CODE:
92395
CAPACITY:6CENSUS: 3DATE:
03/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Juliet See- LicenseeTIME COMPLETED:
04:40 PM
NARRATIVE
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On 3/14/24, Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with licensee, Juliet See and introduced self and stated purpose of the visit. LPA was informed that there are currently 3 residents home.

The facility has 3 bedrooms, 2 bathrooms, kitchen, dining area, living room, family room, attached garage, and backyard. LPA completed a walk through of 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 71 degrees fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected resident bathrooms; bathrooms were clean and appliances were found functional. LPA observed that the master bedroom that is occupied by two residents is used as a passageway to the bathroom for all residents. Deficiency issued. Water temperature tested at 113.6 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, fire extinguisher and first aid kit. Posters such as; the personal rights, ombudsman and emergency disaster plans were posted in a common area. LPA observed cleaning supplies, chemicals and staff medication made accessible to residents. Deficiency issued. There was a designated storage space for resident/staff files. LPA observed the filing cabinet with resident records was unlocked. Technical violation issued. Resident medications were observed secured and inaccessible to residents. There is no swimming pool, bodies of water, guns or ammunition in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care.

Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Facility has a wide variety of food available for residents. Dishes, cups, and utensils were also stored properly.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle EcheverriaTELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2024
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 03/14/2024 04:28 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: SEEGAL RESIDENTIAL CARE
FACILITY NUMBER: 366412436

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

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 in ensuring that at least one staff with an active first aid/CPR certification was present in the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/14/2024
Plan of Correction
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Licensee renewed her first aid/CPR certification during the inspection visit. POC is clear.
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: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle EcheverriaTELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/14/2024 04:28 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: SEEGAL RESIDENTIAL CARE
FACILITY NUMBER: 366412436

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which 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 in making cleaning solutions, chemicals and medication accessible which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2024
Plan of Correction
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Licensee states that she will store all cleaning solutions, chemicals and medication in a locked area. Licensee states that she will submit a statement of understanding to LPA via email by POC due date.
Type B
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed 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 in requesting and submitting criminal background clearance for her son who resides in the home and recently became an adult which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2024
Plan of Correction
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Licensee states that she will submit criminal background clearance for her son and associate him to the facility. Licensee will submit proof to LPA via email by 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: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle EcheverriaTELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/14/2024 04:28 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: SEEGAL RESIDENTIAL CARE
FACILITY NUMBER: 366412436

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)
Resident Records
(b) Each resident's record shall contain at least the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in maintaining complete resident records which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2024
Plan of Correction
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Licensee states that she will review and update all the residents files and gather the missing signatures, initials and documents from the residents or assigned representative. Licensee will submit proof to LPA via email by POC due date.
Type B
Section Cited
CCR
87307(a)(2)(C)
(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply:
(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements:
(C)No bedroom of a resident shall be used as a passageway to another room, bath or toilet.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by allowing all residents use the resident occupied master bedroom as a passageway to the bathroom for all residents which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2024
Plan of Correction
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Licensee states that she will allow the resident that does not sleep in the master bedroom use the hallway bathroom. Licensee states that she will submit a statement of understanding on the regulation cited to LPA via email by 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: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle EcheverriaTELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2024
LIC809 (FAS) - (06/04)
Page: 4 of 6


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SEEGAL RESIDENTIAL CARE
FACILITY NUMBER: 366412436
VISIT DATE: 03/14/2024
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Yards/Outside: One shaded patio, a side gate with self-latching handle on the left and right 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: LPA reviewed 2 resident files for admission agreements, updated physician reports, pre-placement appraisals and needs and services plans. LPA observed incomplete documents, missing signatures, and initials on the records reviewed. Deficiency issued. LPA also reviewed 2 staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA observed that the staff present in the facility had an expired first aid/CPR certification. Deficiency issued. LPA observed that the licensee did not request and submit a criminal background clearance for her son. Deficiency issued. Medications were audited at random and appeared to be dispensed appropriately by staff. Emergency Disaster Drill was last conducted on 1/8/24. LPA observed the Emergency Disaster Plan last reviewed on 04/09/23.

Deficiencies and one technical violation were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102TV and appeal rights were discussed and copies were provided to licensee, Juliet See.

SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle EcheverriaTELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024
LIC809 (FAS) - (06/04)
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