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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366413177
Report Date: 05/17/2023
Date Signed: 05/17/2023 03:24:38 PM

Document Has Been Signed on 05/17/2023 03:24 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:D'ADAMS FAMILY CAREFACILITY NUMBER:
366413177
ADMINISTRATOR:PANOPIO, LEODIGAERLFACILITY TYPE:
735
ADDRESS:11665 CIBOLA ROADTELEPHONE:
(760) 240-1471
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92308
CAPACITY: 5CENSUS: 4DATE:
05/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Leodigaerlan Panopio-AdministratorTIME COMPLETED:
03:30 PM
NARRATIVE
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On 05/17/23 at 08:35 AM, Licensing Program Analyst (LPA) Michelle Echeverria arrived at the facility unannounced to conduct a required Annual visit. LPA was greeted by Caregiver, Erlinda Spears and granted entrance. LPA introduced self and stated the purpose of the visit. LPA observed that there is currently 3 residents in the facility and 1 resident in day program. LPA began the tour of the facility with Caregiver Spears and ended the tour with Administrator, Leodigaerlan Panopio, who later arrived.

The facility has 5 bedrooms (4 for residents and 1 for staff), 2 bathrooms, a kitchen, dining area, living room, and backyard. LPA conducted a general overall inspection, which included, but was not limited to, the following:

Physical Plant: There are no obstructions to indoor and outdoor passageways. The facility is maintained at a 75 degrees Fahrenheit temperature. LPA inspected residents bedrooms; they are equipped with required furniture per regulations except for Resident (R1) bedroom. LPA observed that (R1) closet had boxes with diapers that the facility was using as storage. Technical violation issued. An adequate supply of linens stored in the hallway closet. LPA inspected residents bathrooms; bathrooms were clean and appliances were operating appropriately. LPA observed the drawer in the resident's bathroom broken. Deficiency issued. LPA tested the water temperature in the kitchen faucet which tested at 119.4 degrees Fahrenheit. The facility is equipped with operating fire extinguisher, smoke detectors and carbon monoxide alarms. Posters such as; the facility's license, personal rights, and visitor rules were posted in a common area. LPA observed that the emergency and disaster plan had not been reviewed since 10/07/15. Deficiency issued. Sharps and knives were kept locked in the kitchens cabinet. LPA observed cleaning supplies and toxins unlocked in the laundry's cabinet along with rubbing alcohol in (R1) bathroom beneath the sink inside the cabinet. Deficiency issued. There was a designated locked storage space for residents/staff files, first aid kit and medication. There are no pools, bodies of water, firearms or ammunition.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2023
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 7
Document Has Been Signed on 05/17/2023 03:24 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 05/17/2023 at 01:23 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: D'ADAMS FAMILY CARE
FACILITY NUMBER: 366413177

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that 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 and interview, the Administrator did not comply with the section cited above in making chemicals accessible to 4 out 4 residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/18/2023
Plan of Correction
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Administrator locked the chemicals and removed the rubbing alcohol from (R1) bedroom. Administrator stated that he will review 80087(g) along with staff and submit proof by POC date.
Type A
Section Cited
CCR
80068(a)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the Administrator did not comply with the section cited above in not having admission agreement for 4 out 4 residents which poses an immediate health, safety and personal rights risk to persons in care.
POC Due Date: 05/18/2023
Plan of Correction
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Administrator stated that he will have complete admission agreement for the 4 residents in care and submit proof by POC 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 Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/17/2023 03:24 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 05/17/2023 at 01:23 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: D'ADAMS FAMILY CARE
FACILITY NUMBER: 366413177

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80076(a)(1)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. Each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan -Daily Food Guide for the age group served. All food shall be selected, stored, prepared and served in a safe and healthful manner.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the Administrator did not comply with the section cited above in not providing safe and of quality food to 4 out 4 residents which poses an immediate health, safety and personal rights risk to persons in care.
POC Due Date: 05/18/2023
Plan of Correction
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Administrator disposed the expired food. Administrator stated that he will review 80076(a)(1) along with staff and submit proof by POC date.
Type A
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the Administrator did not comply with the section cited above in not providing sufficient food for 4 out 4 residents which poses an immediate health, safety and personal rights risk to persons in care.
POC Due Date: 05/18/2023
Plan of Correction
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Administrator stated that he will supply the refrigerator and pantry with safe and of quality food and submit a copy of the receipt and picture of the food by POC 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 Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2023


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 05/17/2023 03:24 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 05/17/2023 at 01:23 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: D'ADAMS FAMILY CARE
FACILITY NUMBER: 366413177

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the Administrator did not comply with the section cited above in not having the bathroom in good repair for 4 out of 4 residents which poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 05/23/2023
Plan of Correction
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Administrator stated that he will get the residents bathroom drawer fixed and submit a picture as proof by POC date.
Type B
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the Administrator did not comply with the section cited above in having medication accessible to 4 out 4 residents which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/23/2023
Plan of Correction
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Administrator removed the medication from the refrigerator. Administrator stated that he will review 80075(k)(1) along with staff and submit proof by POC 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 Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2023


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 05/17/2023 03:24 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 05/17/2023 at 01:23 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: D'ADAMS FAMILY CARE
FACILITY NUMBER: 366413177

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(d)
Other Provisions
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee, administrator, or regulated individual shall sign and date the documentation to indicate that the plan has been reviewed and updated as necessary.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the Administrator did not comply with the section cited above in not updating the emergency disaster plan and making it available which poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 05/23/2023
Plan of Correction
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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 Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2023


LIC809 (FAS) - (06/04)
Page: 5 of 7
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: D'ADAMS FAMILY CARE
FACILITY NUMBER: 366413177
VISIT DATE: 05/17/2023
NARRATIVE
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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 and two sheds used facility's storage. All outdoor pathways were free of obstructions.

Food Service: LPA observed lots of expired food inside the refrigerator and pantry dating as far back as 2018. Deficiency issued. Non-perishable and perishable food supply is not sufficient for number of residents in care. Deficiency issued. LPA observed staff's refrigerated medication stored in the refrigerator made accessible to residents in care. Deficiency issued. Dishes, cups, and utensils were also stored properly.

Record Review: LPA reviewed resident files for admission agreements, updated physician reports, and emergency contacts. LPA observed that (R1) complete file is missing. LPA also observed that the admission agreements were missing for the other three residents who pay for cable services in the facility. Deficiency issued. LPA reviewed staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. P & I funds were counted at random and matched with the ledger. Medications were audited at random and appeared to be dispensed appropriately by staff.

Technical violation and deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102 and appeal rights were discussed and copies were provided to Administrator, Leodigaerlan Panopio.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
LIC809 (FAS) - (06/04)
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