366424399-4-26-2023-56-AS-ACON-CR9RSB-20230426131629

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366424399
Report Date: 04/26/2023
Date Signed: 04/26/2023 01:16:39 PM

Document Has Been Signed on 04/26/2023 01:16 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:	SUNNY LANE MANOR		FACILITY NUMBER:	366424399
ADMINISTRATOR:	RAMELLE LLADONES		FACILITY TYPE:	735
ADDRESS:	15351 KIMBALL ST.		TELEPHONE:	(760) 669-0045
CITY:	HESPERIA	STATE: CA	ZIP CODE:	92345
CAPACITY: 4		CENSUS: 3	DATE:	04/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Jeannie Boyle, Care Provider		TIME COMPLETED:	01:15 PM

NARRATIVE

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Licensing Program Analyst (LPA Coleman) Amber Coleman and Michelle Echeverria, (LPA) made an unannounced visit to the facility for the purpose of conducting and Annual Inspection. LPAs met with Care Provider, Jeannie Boyle, (JB), who invited LPAs inside facility and provided a space to work. JB contacted Administrator, who arrived later during the visit. JB informed LPAs the current census is 3.

LPA completed a walk through of the facility and review of staff and resident records.

Facility: The Facility is licensed for four (4) ambulatory adults, ages 18 -59. LPA Coleman observed that the facility is operating in the capacity and conditions approved by Community Care Licensing (CCL).

Physical Plant: LPA Coleman observed the facility's temperatures to be comfortable. Showers and toilets are operable. Extra Linens and hygiene items were located in a hallway closest. Each room is equipped with mattresses, nightstands and appropriate lighting to ensure residents comfort and safety. The facility is equipped with smoke/carbon monoxide detectors. The last fire/earthquake drill last conducted 3/2/23.

Food Service: Nonperishable and perishable food is sufficient for number of residents in care. Food is being prepared and stored properly. Facility has a variety of food available for residents.
Care & Supervision: Facility has sufficient care staff; toxic items are inaccessible to residents in care and stored and locked in a filing cabinet in the office.
Record Review and Resident/Staff Files: LPA Coleman reviewed records for all three (3) residents currently living at the facility. One (1) out of three (3) resident records were found to be incomplete. Physician's Report being out of date. LPA Coleman additionally reviewed all two (2) staff files and confirmed that staff records reflect current CPR/First Aid Certification and Criminal Record Clearance.
Administration: Disaster Plan, Ombudsman poster, Administrator Certificate, and facility license are posted through out the facility. Emergency Disaster Plan is current.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023

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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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: SUNNY LANE MANOR	FACILITY NUMBER: 366424399
	VISIT DATE: 04/26/2023

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Medication/Medical Related Services: LPA Coleman observed that the residents' medication is centrally stored and secured in a file cabinet in the office. LPA Coleman reviewed all the residents' medications and compared it to the facility's Medication Administration Report (MARs) and Centrally Stored Medication Log. LPA Coleman did not observe any medication errors at this time.

Based on the observations made during today’s visit, deficiencies are being cited per Title 22, Division 6, of the California Code or Regulations. An exit interview to review this report was conducted and a copy of this report was provided to facility representative.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/26/2023 01:16 PM - It Cannot Be Edited

Created By: Amber Coleman On 04/26/2023 at 01:03 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: SUNNY LANE MANOR	FACILITY NUMBER: 366424399
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80069(d)(1)

Client Medical Assessments

(d) In addition to Section 80069(c), the medical assessment for clients in ARFs shall include the following: (1) A physical examination of the person, indicating the physician's primary diagnosis and secondary diagnosis, if any. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 out of 3 resident files were missing the LIC602. Which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/26/2023
	Plan of Correction
1 2 3 4	Administrator will assist the resident in getting reevaluated by their Primary Care Physican as well as obatin an updated LIC602 form. Proof of the comleted LIC602 to be submitted to the Community Care Licesing Office within the next 30 day.

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:

Amber Coleman

LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023

LIC809 (FAS) - (06/04)

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