366424647-10-19-2024-56-AS-MECA-DA7PF4-20241019111608

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366424647
Report Date: 10/19/2024
Date Signed: 10/19/2024 11:16:17 AM

Document Has Been Signed on 10/19/2024 11:16 AM - 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:	ANDREW CARE CENTER		FACILITY NUMBER:	366424647
ADMINISTRATOR:	RUFINA C. LAYGO		FACILITY TYPE:	740
ADDRESS:	13821 CRONESE WAY		TELEPHONE:	(760) 946-5829
CITY:	APPLE VALLEY	STATE: CA	ZIP CODE:	92307
CAPACITY:	6	CENSUS: 3	DATE:	10/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Sulema Smith-Staff		TIME COMPLETED:	11:38 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Michelle Echeverria made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Staff, Sulema Smith and was granted entry to the facility. LPA was accompanied by Sulema to conduct a general overall inspection, which included, but was not limited to, the following: The facility has 4 bedrooms, 2 bathrooms, kitchen, 2 dining areas, living room, laundry room, office, attached garage, and backyard. The facility is vendorized by Inland Regional Center. LPA completed a walk through of the facility, review of records, P&I and medication audit. Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 73 degrees fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected resident bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 105.6 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, charged fire extinguisher, and first aid kit. Posters such as; the personal rights, CCL complaint poster, ombudsman, emergency disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, medications and other dangerous items were kept in secure cabinets inaccessible to residents. Residents/Staff files and P&I were observed locked and made inaccessible. The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care. Food Service: LPA observed 2 days of perishables and 7 days non-perishables food, pantry stocked and up to date. Facility has a variety of food available. Dishes, cups, and utensils were stored properly

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2024

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: ANDREW CARE CENTER	FACILITY NUMBER: 366424647
	VISIT DATE: 10/19/2024

NARRATIVE

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Yards/Outside: One shaded patio, an inaccessible shed used for storage, and a side gate with self-latching handle on the left and right side of the house that leads into the backyard. All outdoor pathways were free of obstructions. LPA observed that the facility did not have window screens. Deficiency issued.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPA reviewed resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. P& I and medication were audited and matched with record. The facility last conducted an earthquake and fire drill on 10/1/24. LPA observed that the Emergency Disaster Plan was not reviewed/updated annually. Technical violation issued.

One deficiency and one technical violation were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102TV and appeal rights were discussed and copies were provided to Administrator, Rufina Laygo who later arrived.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/19/2024 11:16 AM - It Cannot Be Edited

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: ANDREW CARE CENTER	FACILITY NUMBER: 366424647
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(c)

Maintenance and Operation

(c) All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the Administrator did not comply with the section cited above in providing window screens which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/02/2024
	Plan of Correction
1 2 3 4	Administrator stated that she will have screens installed on the windows and submit pictures as proof to LPA via text message.

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	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2024

LIC809 (FAS) - (06/04)

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