<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425203
Report Date: 10/30/2023
Date Signed: 10/30/2023 01:14:29 PM

Document Has Been Signed on 10/30/2023 01:14 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:MCCOLLUM'S HOPE RANCHFACILITY NUMBER:
366425203
ADMINISTRATOR:GOUCHER, KATHYFACILITY TYPE:
735
ADDRESS:589 FERN DRIVETELEPHONE:
(909) 336-9710
CITY:TWIN PEAKSSTATE: CAZIP CODE:
92391
CAPACITY: 6CENSUS: 3DATE:
10/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:36 AM
MET WITH:Kathy GoucherTIME COMPLETED:
01:19 PM
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 Analysts (LPAs) Anna Bueno and Bianca Wolcott made an unannounced visit to the facility to conduct a required annual inspection. LPAs identified themselves to clients who were advised of the purpose of the visit. Licensee/administrator arrived shortly.

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

LPAs Bueno and Wolcott and Licensee Goucher toured the interior and exterior of the facility. The facility has no bodies of water. There is a shaded area in the deck for client use. LPAs Bueno and Wolcott and Licensee observed that the area around the home was free of obstruction. The facility had a working telephone for use. The facility fire extinguisher was last inspected on 7/25/23. LPA Bueno and Licensee Goucher tested the living room and hallway smoke alarms and found the units to be in working order. A locked centralized closet is used for medications while client and staff files and facility records are kept secured in the office area. Sharps, toxins, and cleaning agents are kept secured and locked in closets.

The following were observed of the physical plant:
Client Bedrooms and Bathroom: LPAs Bueno and Wolcott and Licensee Goucher observed all bedrooms to have the required bedding and furniture, such as, clean mattresses/linen, sufficient storage space, and lighting. The facility had a supply of additional linens and towels. LPAs and Licensee observed bathrooms were kept in sanitary conditions and provisions for hygiene items are available.
Kitchen and Dining Areas: LPAs and Licensee inspected the kitchen and found dishes, glasses, and utensils were in good condition and stored in a safe manner. LPAs and Licensee inspected food provisions and found a 2-day supply of perishable food and 7-day supply of non-perishable food items. LPAs reviewed the facility menu.
Common (living/activity) areas: LPAs Bueno and Wolcott and Licensee Goucher observed adequate seating in common areas. Calendar of activities was available for review.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2023
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 3
Document Has Been Signed on 10/30/2023 01:14 PM - It Cannot Be Edited


Created By: Anna Bueno On 10/30/2023 at 12:34 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: MCCOLLUM'S HOPE RANCH
FACILITY NUMBER: 366425203

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1503.2
General Provisions
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPAs Bueno and Wolcott and Licensee Goucher observation, Licensee did not comply with the section cited above as no carbon monoxide detector was located in the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/09/2023
Plan of Correction
1
2
3
4
Licensee shall install a carbon monoxide detector in the facility no later than the end of POC date.
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:Anna Bueno
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
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: MCCOLLUM'S HOPE RANCH
FACILITY NUMBER: 366425203
VISIT DATE: 10/30/2023
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
26
27
28
29
30
31
32
The following records were inspected:
Client Records: LPAs Bueno and Wolcott and Licensee Goucher inspected three client files and found all to have the required documentation, including but not limited to, placement and admissions agreement, and current Individual Program Plan.
Staff Records: LPAs reviewed staff file. Administrator certificate is current. LPAs reviewed training and disaster drill logs.
Centralized Medication: LPAs reviewed client medications. LPAs observed all scheduled medications were administered as prescribed.

LPAs Bueno and Wolcott and Licensee Goucher were unable to locate a carbon monoxide sensor. 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 Licensee at the conclusion of the inspection.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3