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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425143
Report Date: 05/09/2024
Date Signed: 05/09/2024 12:36:23 PM

Document Has Been Signed on 05/09/2024 12:36 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:JEREMIAH HOMEFACILITY NUMBER:
366425143
ADMINISTRATOR/
DIRECTOR:		NEZART, PAMELAFACILITY TYPE:
735
ADDRESS:1706 BLUE WING COURTTELEPHONE:
(909) 389-1486
CITY:REDLANDSSTATE: CAZIP CODE:
92374
CAPACITY: 4CENSUS: 4DATE:
05/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Jerome Nezart - LicenseeTIME VISIT/
INSPECTION COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced required 1-year visit to the facility. LPA met with Jerome Nezart, Licensee, and discussed the purpose of the visit.

The facility is a level (2) Adult Residential Facility (ARF) with a current census of (4) clients. LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:

Operation/Physical Plant: The facility has a fire clearance for four (4) ambulatory clients. The facility’s Indoor and outdoor passageways are kept free of obstruction. The facility's jacuzzi was observed secured with a locked cover. The facility’s has sufficient indoor and outdoor activity space for clients in care. The facility’s outdoor activity area is fenced with a self-latching gate. The facility has sufficient lighting and is maintained at a comfortable temperature. The facility has operating telephone service, laundry equipment and fire/carbon monoxide alarms. The facility sufficient supply of bed linen, towels, and hygiene products for clients in care. Client bedrooms were equipped with beds, bed linen, chairs, storage space and sufficient lighting. Client bathroom toilets, hand washing basins and showers were operating in safe and sanitary conditions. The hot water in client bathrooms tested at 105 and 108 degrees F. Sharps, disinfectants and cleaning solutions are kept in a locked cabinet. The facility has posted in a common area: house rules, facility license, individual rights, and Community Care License complaint poster

Food Service: The kitchen and dining areas are maintained clean. The facility has sufficient non-perishable and perishable food for number of clients in care. The facility’s freezer temperatures were maintained at zero degrees. The facility’s refrigerator temperatures were maintained at 27 and 35 degrees F. A written menu was posted in the dining area. The facility has sufficient cups, plates, and utensils for client use.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2024
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: JEREMIAH HOME
FACILITY NUMBER: 366425143
VISIT DATE: 05/09/2024
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Health Related Services: Client medications are labeled and centrally stored in a locked cabinet. The facility has first aid manuals and complete first aid kits.

Personnel/Client Records: Staff records were observed to complete. Client records were observed to be complete. Administrator’s certification is current. The last fire drill was conducted on 4/11/2024.

Based on LPA observations, the following deficiencies are being cited per Title 22 of the California Code of Regulations and documented on report LIC809-D: The facility did not have a written and complete disaster plan on file for review. The facility did not have night lights in hallways leading to nonprivate client bathrooms.



This report was reviewed and copies of the report was provided to the Licensee at the conclusion of the visit.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/09/2024 12:36 PM - It Cannot Be Edited


Created By: Magda Malcore On 05/09/2024 at 11:47 AM
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: JEREMIAH HOME
FACILITY NUMBER: 366425143

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(e)(2)
Fixtures, Furniture, Equipment, and Supplies
(e) Emergency lighting, which shall include at a minimum working flashlights or other battery-powered lighting, shall be maintained and readily available in areas accessible to clients and staff. (2) Night lights shall be maintained in hallways and passages to nonprivate bathrooms.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations, the licensee did not comply with the section cited above by the facility did not have night lights in hallways leading to nonprivate client bathrooms; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2024
Plan of Correction
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The Licensee shall submit to the Licensing Agency proof of operating nightlights by POC due date.
Type B
Section Cited
CCR
80023(a)
Disaster & Mass Casualty Plan
(a) Each licensee shall have and maintain on file a current, written disaster and mass casualty plan of action.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations, the licensee did not comply with the section cited above by not maintaining a written and complete disaster plan on file for review, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2024
Plan of Correction
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The Licensee shall submit to the Licensing Agency a complete disaster plan by POC due date.
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:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2024


LIC809 (FAS) - (06/04)
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