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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366424637
Report Date: 10/19/2023
Date Signed: 10/19/2023 02:54:03 PM

Document Has Been Signed on 10/19/2023 02:54 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
, CA 92507
FACILITY NAME:NEW DISCOVERY RESIDENTIAL SERVICES IFACILITY NUMBER:
366424637
ADMINISTRATOR:VIVIAN FRANCISCOFACILITY TYPE:
735
ADDRESS:26278 DATE STREETTELEPHONE:
9092809644
CITY:HIGHLANDSTATE: CAZIP CODE:
92346
CAPACITY: 6CENSUS: 4DATE:
10/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:39 AM
MET WITH:Vivian FranciscoTIME COMPLETED:
03:56 PM
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Licensing Program Analyst (LPA) Anna Bueno made an unannounced visit to the facility to conduct a required annual inspection. LPA identified herself to direct support professional (DSP) Kevon Clardy who was advised of the purpose of the visit. DSP Clardy phoned administrator Vivian Francisco; Francisco arrived during the visit.

The facility is currently licensed as an Adult Residential Facility, vendored by the Inland Regional Center. The facility has capacity of four ambulatory clients. Three staff and three clients are present at the facility during today's visit.

LPA Bueno and DSP Clardy toured the interior and exterior of the facility. The facility has no bodies of water. There is a shaded area in the backyard for client use. LPA and DSP observed that side gate was unlocked and free of obstruction. The facility had a working telephone for use. The facility fire extinguisher was last inspected by staff on 10/7/23 and LPA observed the fire extinguisher to be charged. DSP tested the living room smoke alarm and found the unit to be in working order. LPA and DSP observed other smoke alarms in the facility were interconnect and began chiming afterwards. A locked centralized cabinet is used for medications while client and staff files and facility records are kept secured in a locked office. Sharps, toxins, and cleaning agents are kept secured and locked in closets and cabinets..

The following were observed of the physical plant:
Client Bedrooms and Bathroom: LPA Bueno and DSP Clardy observed all bedrooms to have the required bedding and furniture, such as, clean mattresses/linen, sufficient storage space, chairs, and lighting. The facility had a supply of additional linens and towels. LPA and DSP observed bathrooms were kept in sanitary conditions and provisions for hygiene items are available.
Kitchen and Dining Areas: LPA and DSP inspected the kitchen and found dishes, glasses, and utensils were in good condition and stored in a safe manner. LPA and DSP inspected food provisions and found a 2-day supply of perishable food and 7-day supply of non-perishable food items. LPA and Administrator reviewed the facility menu.
Common (living/activity) areas: LPA and DSP observed adequate seating in the common areas. LPA observed activities in the office. Facility staff updated the calendar of activities.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2023
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: NEW DISCOVERY RESIDENTIAL SERVICES I
FACILITY NUMBER: 366424637
VISIT DATE: 10/19/2023
NARRATIVE
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The following records were inspected:
Client Records: LPA Bueno inspected four client files and found all to have the required documentation, including but not limited to, placement and admissions agreement, current Individual Program Plan (IPP), and P&I.
Staff Records: LPA reviewed four staff files. Administrator certificate is current. LPA reviewed training and disaster drill logs.
LPA and Administrator observed that no staff working on duty has a current CPR/First aid
Centralized Medication: LPA reviewed client medications. LPA and Licensee observed all scheduled medications were administered as prescribed.

LPA and Administrator observed that three of three staff working during this shift did not have an active First Aid/CPR certification. This poses a potential health and safety risk to clients in care. Refer to LIC 809D for deficiency cited. An exit interview was conducted where this report was provided to Administrator Francisco at the conclusion of the inspection.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/19/2023 02:54 PM - It Cannot Be Edited


Created By: Anna Bueno On 10/19/2023 at 02:36 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
, CA 92507

FACILITY NAME: NEW DISCOVERY RESIDENTIAL SERVICES I
FACILITY NUMBER: 366424637

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Bueno and Administrator Francisco staff records review, the licensee did not comply with the section cited above in as three of three staff present at the facility before Administrator's arrival did not have a current CPR/First Aid certification, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/06/2023
Plan of Correction
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Licensee shall arrange training for all staff with expired First Aid/CPR certification. Licensee shall provide proof of certification no later than end of POC 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:Anna Bueno
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023


LIC809 (FAS) - (06/04)
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