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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425203
Report Date: 11/04/2024
Date Signed: 11/05/2024 08:30:45 AM

Document Has Been Signed on 11/05/2024 08:30 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:MCCOLLUM'S HOPE RANCHFACILITY NUMBER:
366425203
ADMINISTRATOR/
DIRECTOR:		GOUCHER, KATHYFACILITY TYPE:
735
ADDRESS:589 FERN DRIVETELEPHONE:
(909) 336-9710
CITY:TWIN PEAKSSTATE: CAZIP CODE:
92391
CAPACITY: 6CENSUS: 3DATE:
11/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:06 PM
MET WITH:Administrator, Kathleen GoucherTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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On 11/04/2024 at 1:06 PM, Licensing Program Analysts (LPAs) Renese Howell-Small and Magda Malcore conducted an unannounced visit to the facility to conduct the required comprehensive annual inspection to the facility. LPAs Small and Malcore were greeted by a staff and gained access to the home. Licensee/Administrator Kathleen Goucher was informed of the visit. LPAs explained the purpose of the visit to Licensee/Administrator Kathleen Goucher .

The facility has four (4) bedrooms, two and a half (2.5) bathrooms, kitchen, dining room, living room, attached garage, and backyard. The facility is vendorized by Inland Regional Center (IRC). LPAs completed a walk through of the facility, review of records, and medications audit.



Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD), LPAs observed three (3) clients during the visit. There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 63 degrees Fahrenheit. LPAs inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, chairs, and sufficient lighting. LPAs Small and Malcore inspected client bathrooms; bathrooms were clean, and appliances were found functional. Water temperatures tested at 106.1 degrees Fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide detectors, charged fire extinguisher, and first aid kit with first aid book.

Posters such as; the personal rights, labor laws, and emergency disaster plan were posted in a common area. Client medications were kept in secure cabinets inaccessible to clients. LPAs observed two night lights in the hallway leading to clients' shared bathrooms. The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility.
*** Continuation in LIC809C ***
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2024
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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MCCOLLUM'S HOPE RANCH
FACILITY NUMBER: 366425203
VISIT DATE: 11/04/2024
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Yards/Outside: One shaded patio locate in the front of the residence and on the side and an attached two (2) car garage observed. All outdoor pathways were free of obstructions.

Food Service: LPAs Small and Malcore bserved two (2) day(s) supply of perishable food and seven (7) day(s) supply of non-perishables food and snacks. Dishes, cups, and utensils were stored properly.


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

Record Review: LPAs reviewed three (3) client files for admission agreements, medical assessments/physician reports and Individual Program Plan (IPP). LPAs observed files reviewed were complete. LPAs also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test result. LPAs observed the files to be complete.

LPAs audited three (3) clients’ medications and one issue was observed. Administrator Kathleen confirmed that all residents have their own ATM cards and handle their own cash.

One (1) deficiency was cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, (LIC809D), Technical Assistance 9102 and (Appeal Rights) were discussed, and copies were provided to Licensee/Administrator Kathleen Gouchers

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/05/2024 08:30 AM - It Cannot Be Edited


Created By: Renese Howell-Small On 11/04/2024 at 03:36 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
RIVERSIDE, CA 92507

FACILITY NAME: MCCOLLUM'S HOPE RANCH
FACILITY NUMBER: 366425203

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80070(b)(10)
Client Records
(b) Each record must contain information including, but not limited to, the following: (10) Record of current medications, including the name of the prescribing physician, and instructions, if any, regarding control and custody of medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review , the licensee did not comply with the section cited above by not ensuring the resident's medication was given according to the physician's orders, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2024
Plan of Correction
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Licensee/Administrator Kathleen made two telephone calls to resident #1's physician for a prescription or confirmation that the supplement can be given during our vist.
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:Karen Clemons
LICENSING EVALUATOR NAME:Renese Howell-Small
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2024


LIC809 (FAS) - (06/04)
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