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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366423467
Report Date: 08/24/2021
Date Signed: 08/24/2021 03:52:37 PM

Document Has Been Signed on 08/24/2021 03:52 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:NEW DISCOVERY RESIDENTIAL SERVICES #5FACILITY NUMBER:
366423467
ADMINISTRATOR:ERICA REYESFACILITY TYPE:
735
ADDRESS:33974 AVENUE "H"TELEPHONE:
(909) 918-0059
CITY:YUCAIPASTATE: CAZIP CODE:
92399
CAPACITY: 4CENSUS: 3DATE:
08/24/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Donna Weldon - AdministratorTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility to follow up on open complaint investigations. LPA Colvin met with Administrator Donna Weldon and during LPA Colvin's inspection LPA Colvin observed the following issues which needed to be addressed:

LPA Colvin observed that all three staff currently at the facility were not on LPA Colvin's list of associated staff, which was printed today. LPA Colvin requested the files for those currently at the facility, and was provided with a full file for S1 (who has been working at the facility since 2014), and files for S2 and the Administrator, which only contained a few papers, none of which confirmed criminal record clearance. Deficiency cited for incomplete staff records. LPA Colvin was informed by Administrator Donna that she just started at the facility, and that S2 had only been working for about 2 weeks. LPA Colvin called into the Riverside Community Care Licensing (CCL) office to confirm clearance for all three staff, which LPA Colvin was able to confirm. LPA Colvin requested that the Administrator contact the Licensee's Human Resources Department and have the criminal record clearance transfer documents emailed to the Administrator, so that LPA Colvin can confirm existence of the requests while at the facility. These documents were eventually provided to LPA Colvin while at the facility, though LPA Colvin observed several errors in the transfer requests, which would have prevented them from being processed/associating the staff to the facility.

The transfer request for the Administrator was signed by another administrator. This is invalid as appointments of Administrators need to be signed by the Licensee or a Director. Secondly, the Administrator's transfer request was made for a separate sister facility (#366424637).

Similarly, the transfer request provided to LPA Colvin for S2 was filled out for another sister facility (#366424638) and not the facility where this staff member works or was present during today's inspection. LPA Colvin will be citing the facility a deficiency for failure to request criminal record clearance transfer for S2 and the Administrator, as neither request provided to LPA Colvin was for this facility.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2021
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 08/24/2021 03:52 PM - It Cannot Be Edited


Created By: Crystal Colvin On 08/24/2021 at 01:07 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: NEW DISCOVERY RESIDENTIAL SERVICES #5
FACILITY NUMBER: 366423467

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
08/25/2021
Section Cited
CCR
80019(e)(2)

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Criminal Record Clearance: (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working...in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 80019(f)... This requirement was not met by:
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Licensee agrees to submit a criminal record clearance transfer request and all required supporting documentation (color copy of ID) to the Riverside/San Bernardino Community Care Licensing Regional Office by the Plan of Correction Date of 8/25/21. Licensee may alternatively associate S2 and Administrator
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Based on record review, the Licensee did not comply with the above regulation with 2 of 3 staff files reviewed. LPA Colvin observed that S2 & Administrator did not have any proof that a criminal record clearance transfer was requested prior to employement. This is an immediate safety risk for all residents in care.
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on the new Guardian system. Proof of submission of documents to CCL or upload to Guardian to be submitted to LPA Colvin by the Plan of Correction date of 8/25/21.
Type B
08/27/2021
Section Cited
CCR80019(j)

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Criminal Record Clearance: (j) The licensee shall maintain documentation of criminal record clearances or criminal record exemptions of employees in the individual's personnel file as required in Section 80066. This requirement was not met as evidenced by:
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Administrator corrected during visit. No further POC required.
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Based on record review, the Licensee did not comply with the above regulation with 2 of 3 staff files reviewed. LPA Colvin observed that S2 & Administrator did not have any proof of criminal record clearance in their staff files at the facility. This is an immediate safety risk for all residents in care.
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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:Joel Esquivel
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2021


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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: NEW DISCOVERY RESIDENTIAL SERVICES #5
FACILITY NUMBER: 366423467
VISIT DATE: 08/24/2021
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LPA Colvin will not be including S1 in the deficiency, as there was a copy of the transfer request in S1's file (for all of the Licensee's facilities), though LPA Colvin informed the Administrator that S1's transfer request will need to be sent again due to it not having been processed previously, or there having been an error in the request back in 2014.

This deficiency comes with a civil penalty in the amount of $100 per day worked by the employee for a maximum of 5 days per employee. Since S2 has been working at the facility for two weeks, LPA Colvin will be issuing a civil penalty in the amount of $500, for the maximum of 5 days. Through review of the staff schedule, LPA Colvin confirmed that Administrator Donna Weldon has been working at the facility since at least the beginning of the month (August 2021). Due to the Administrator working at least 5 days at the facility, LPA Colvin will be citing a civil penalty in the amount of $500 for the maximum of 5 days.
Based on record review, the facility was cited and civil penalties in the amount of $1,000 was issued.

LPA Colvin conducted an exit interview with the Administrator and a copy of this report, LIC809D, Civil Penalty form LIC421BG, and appeal rights were provided.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021
LIC809 (FAS) - (06/04)
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