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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366424637
Report Date: 01/21/2025
Date Signed: 01/21/2025 05:04:08 PM

Document Has Been Signed on 01/21/2025 05:04 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:NEW DISCOVERY RESIDENTIAL SERVICES IFACILITY NUMBER:
366424637
ADMINISTRATOR/
DIRECTOR:		VIVIAN FRANCISCOFACILITY TYPE:
735
ADDRESS:26278 DATE STREETTELEPHONE:
(909) 280-9644
CITY:HIGHLANDSTATE: CAZIP CODE:
92346
CAPACITY: 6CENSUS: 3DATE:
01/21/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:55 PM
MET WITH:Star PillmanTIME VISIT/
INSPECTION COMPLETED:
05:03 PM
NARRATIVE
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On 01/21/2025 at 1:55PM Licensing Program Analyst, Renese Howell-Small (LPA) conducted an unannounced visit to the facility for Case Management purposes. LPA identified self and gained access to the facility by staff, Kevon Clardy, Jr. Administrator, Star Pillman was notified of the reason of the visit and met with LPA approximately thirty minutes (30) after LPA's arrival.

LPA conducted a brief tour of the facility and observed two (2) clients in care. LPA reviewed the Administrator's file and client files for the required documents and obtained necessary copies. LPA interviewed two (2) clients in care and two (2) staff.

LPA observed a hole in the hallway across from the clients' bathroom. LPA observed large white areas on the living room's carpeted floor. Deficiencies will be cited.

An exit interview was conducted where this report LIC809, LIC809D and Appeal Rights were discussed and a copy provided to staff, Kevon Clardy, Jr.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE: DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2025
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 2
Document Has Been Signed on 01/21/2025 05:04 PM - It Cannot Be Edited


Created By: Renese Howell-Small On 01/21/2025 at 04:29 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 I
FACILITY NUMBER: 366424637

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/31/2025
Section Cited
CCR
80087(a)

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80087 (a) Buildings 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 was not met as evidenced by:
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Licensee/Administrator will cover/repair the hole in the hallway and have the carpet in the living room shampooed or cleaned by the Plan of Correction due date and submit proof of the maintenance and repair to LPA.
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Based on interview and observation, Licensee/Administrator did not ensure that the facility's hole in the wall was repaired and the carpet in the living area was maintained in a clean manner, which poses a potential safety, health or personal rights risk to persons in care.
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Type B
01/31/2025
Section Cited
CCR80061(a)(E)

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80061 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency reports ... (E) Any unusual incident...which threatens the physical or emotional health or safety...
This requirement was not met as evidenced by:
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Licensee/Administrator will train staff on Reporting Requirements and submit a signed statement that they have reviewed the Reporting Requirements to LPA by the Plan of Correction due date.
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Based on interview, record review and observation, Licensee/Administrator did not submit an Unusual Injusry Report to the Department, which poses a potential safety, health or personal rights risk to persons 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:Karen Clemons
LICENSING EVALUATOR NAME:Renese Howell-Small
LICENSING EVALUATOR SIGNATURE:
DATE: 01/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/21/2025


LIC809 (FAS) - (06/04)
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