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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366413192
Report Date: 05/16/2023
Date Signed: 05/16/2023 04:45:17 PM

Document Has Been Signed on 05/16/2023 04:45 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:MISTY CARE CENTERFACILITY NUMBER:
366413192
ADMINISTRATOR:PENAFLOR, MAGDALENAFACILITY TYPE:
735
ADDRESS:13868 MISTY PATHTELEPHONE:
(760) 780-0287
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 6CENSUS: 6DATE:
05/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:13 PM
MET WITH:Lorida Martin-CaregiverTIME COMPLETED:
04:50 PM
NARRATIVE
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On 05/16/23 at 01:13 PM, Licensing Program Analyst (LPA) Michelle Echeverria arrived at the facility unannounced to conduct a required Annual visit. LPA was greeted by Caregiver, Lorida Martin. LPA observed that there is currently 2 residents, 2 additional caregivers present in the home and 4 residents in day program. LPA toured the facility inside and outside with caregiver, Lorida Martin.

The facility has 6 bedrooms (5 for residents and 1 for staff), 3 bathrooms, a kitchen, dining area, living room, family room, attached garage, staff office, 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 78 degrees Fahrenheit temperature. LPA inspected residents bedrooms; they are equipped with required furniture per regulations. An adequate supply of linens stored in the hallway closet. LPA inspected residents bathrooms; bathrooms were clean and appliances were operating appropriately. LPA tested the water temperature in the kitchen faucet which tested at 109.4 degrees Fahrenheit. The facility is equipped with operating fire extinguisher, smoke detectors and carbon monoxide alarms. Posters such as; the personal rights,visitor rules, and disaster plans were posted in a common area. Cleaning supplies, toxins, and other dangerous items were kept locked in the laundry room. Sharps and knives were locked in the kitchen's sink bottom cabinet. 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. Emergency kits were found inside the garage. Overall, the facility is clean, in good repair, and operating in safe conditions.
Yards/Outside:
One shaded patio, a 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.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2023
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 05/16/2023 04:45 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 05/16/2023 at 03:46 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: MISTY CARE CENTER
FACILITY NUMBER: 366413192

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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, interview and record review, the Administrator did not comply with the section cited above in making medication accessible to 6 out of 6 residents which poses an immediate health, safety and personal rights risk to persons in care.
POC Due Date: 05/17/2023
Plan of Correction
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Administrator stated that she will store the refrigerated medication inside an iced cooler and lock it inside the office in the meantime. Administrator stated that she will purchase and store medication in a medicine lock box in the refrigerator and submit proof of correction by POC due date.
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: 05/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2023


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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MISTY CARE CENTER
FACILITY NUMBER: 366413192
VISIT DATE: 05/16/2023
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Food Service: LPA observed 2 days of perishables and 7 days non-perishables food, pantry fully stocked and up to date. LPA observed resident's refrigerated medication stored inside the kitchen's refrigerator accessible to residents. Deficiency issued. Facility has a variety of food available. Menu plan is posted on the kitchen's refrigerator. Dishes, cups, and utensils were stored properly. Emergency food and water were observed inside the garage. LPA observed the kitchen's trash can without a tight-fitting cover. Technical violation issued.

Record Review: LPA reviewed the residents files along with the staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings.

Technical violation and deficiency 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 Caregiver, Lorida Martin.

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

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
LIC809 (FAS) - (06/04)
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