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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425514
Report Date: 12/17/2024
Date Signed: 12/17/2024 04:17:07 PM

Document Has Been Signed on 12/17/2024 04:17 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:DAVIS RESIDENTIAL FACILITY-SHERIDANFACILITY NUMBER:
366425514
ADMINISTRATOR/
DIRECTOR:		YVONNE DAVISFACILITY TYPE:
735
ADDRESS:14798 SHERIDAN COURTTELEPHONE:
(760) 524-7806
CITY:ADELANTOSTATE: CAZIP CODE:
92301
CAPACITY: 4CENSUS: 3DATE:
12/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:05 PM
MET WITH:Amber Koppenhaver-Espinoza- Lead StaffTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with Staff, Richard Thompson and introduced self and stated purpose of the visit.

The facility has 3 bedrooms, 2 bathrooms, kitchen, dining area, living room, office area, backyard, and attached garage. LPA completed a walk through of facility and review of records. Medication and P&I audit was not completed due to time restriction.

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 70 degrees fahrenheit. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA observed a broken window screen in the master bedroom, a leaking toilet in the main bathroom. Deficiency issued. LPA observed that all clients and staff are using the client's master bedroom bathroom since the main bathroom is out of service. Deficiency issued. LPA inspected client bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 112 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, state license and CCL complaint poster were posted in a common area. LPA observed accessible chemicals, knives and medication to clients. Deficiency issued. There was a designated storage space for client/staff files. There is no swimming pool, bodies of water, firearm or ammunition in the facility.

Food Service: LPA observed that the facility did not have a week of nonperishables and two days of perishable foods. Deficiency issued. Dishes, cups, and utensils were also stored properly.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2024
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 7
Document Has Been Signed on 12/17/2024 04:17 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 12/17/2024 at 03:07 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: DAVIS RESIDENTIAL FACILITY-SHERIDAN
FACILITY NUMBER: 366425514

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by making accessible chemicals, knives and medication to clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/17/2024
Plan of Correction
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Staff locked chemicals, knives and medication. Licensee will train all staff on regulation cited and submit proof by 12/31/24 to LPA via email.
Type A
Section Cited
CCR
80019(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:

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 having the staff present not subject to criminal record review clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/17/2024
Plan of Correction
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Lead staff stated that staff without criminal record review clearance will not be left alone with clients and will have that staff submit criminal record review clearance by 12/31/24 and send proof to LPA via email along with a statement of understanding from licensee.
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:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 12/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2024


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 12/17/2024 04:17 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 12/17/2024 at 03:07 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: DAVIS RESIDENTIAL FACILITY-SHERIDAN
FACILITY NUMBER: 366425514

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by not having 7 days of nonperishable foods and 2 days of perishable foods which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/18/2024
Plan of Correction
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Lead staff stated that she will purchase 7 days of nonperishable foods and 2 days of perishable foods and send pictures of food and receipt as proof to LPA via text message by POC due date.
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:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 12/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2024


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 12/17/2024 04:17 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 12/17/2024 at 03:07 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: DAVIS RESIDENTIAL FACILITY-SHERIDAN
FACILITY NUMBER: 366425514

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(c)(1)(D)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022.  (1) The Infection Control Plan shall include all of the following:  (D) The licensee shall review the use of infection control procedures in the facility at least annually, if local government public health determines an epidemic outbreak has occurred, or if the review is requested by the local licensing agency. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above by not updating/reviewing the Infection Control Plan which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/24/2024
Plan of Correction
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Lead staff stated that she will have licensee submit an updated/reviewed Infection Control Plan to LPA via email by POC due date.
Type B
Section Cited
CCR
80087(a)
Building 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 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 having a broken window screen in the master bedroom, a leaking toilet in the main bathroom which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/24/2024
Plan of Correction
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Lead staff stated that the bathroom will be repaired and window screen replaced by POC due date. Pictures and video will be sent to LPA via mobile.
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:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 12/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2024


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 12/17/2024 04:17 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 12/17/2024 at 03:07 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: DAVIS RESIDENTIAL FACILITY-SHERIDAN
FACILITY NUMBER: 366425514

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85087(a)(4)
Building and Grounds
(4) No client bedroom shall be used as a public or general passageway to another room, bath or toilet.

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 using the client's master bedroom bathroom for everyone's use which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/24/2024
Plan of Correction
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Lead staff stated that she will inform licensee to submit a statement of understanding on the deficiency cited and send to LPA via email by POC due date.
Type B
Section Cited
CCR
80025(b)
Bonding
(b) All licensees, other than governmental entities, who are entrusted to care for and control clients' cash resources shall file or have on file with the licensing agency, a bond issued by a surety company to the State of California as principal.

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 providing proof of a surety bond which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/24/2024
Plan of Correction
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Lead staff stated that she will have the licensee submit a copy of an active surety bond to LPA via email 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:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 12/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2024


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 12/17/2024 04:17 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 12/17/2024 at 03:07 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: DAVIS RESIDENTIAL FACILITY-SHERIDAN
FACILITY NUMBER: 366425514

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(f)
Administrator Qualifications and Duties
(f) When the administrator is absent from the facility there shall be coverage by a designated substitute, who meets the qualifications of Section 80065, who shall be capable, of, and responsible and accountable for, management and administration of the facility in compliance with applicable law and regulation.

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 having a designated substitue which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/24/2024
Plan of Correction
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Lead staff stated that she will inform licensee to submit a completed designated substitute form to LPA via email by POC due date.
Type B
Section Cited
HSC
1565(d)
Other Provisions
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee, administrator, or regulated individual shall sign and date the documentation to indicate that the plan has been reviewed and updated as necessary.

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 reviewing/updating the emergency disaster plan annually which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/24/2024
Plan of Correction
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Lead staff stated that she will have the licensee review/update the emergency disaster plan and send proof to LPA via email 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:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 12/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2024


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: DAVIS RESIDENTIAL FACILITY-SHERIDAN
FACILITY NUMBER: 366425514
VISIT DATE: 12/17/2024
NARRATIVE
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Yards/Outside: One shaded patio, and side gate with self-latching handle on the left side of the house that leads into the backyard. All outdoor pathways were free of obstructions.

Record Review: LPA reviewed administrator and staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA observed that one current staff present did not have criminal record clearance. Deficiency with civil penalty issued. LPA reviewed client files for admission agreements, updated physician reports, and needs and services plans. LPA observed that the Infection Control Plan was not reviewed/updated since 10/6/22. Deficiency issued. LPA observed no proof of an active surety bond. Deficiency issued. LPA observed that the administrator is on vacation and there is no designated substitute for coverage. Deficiency issued. LPA observed an incomplete emergency disaster plan not reviewed/updated. Deficiency issued.

Deficiencies and one civil penalty were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC421BG and appeal rights were discussed and copies were provided to lead staff, Amber Koppenhaver-Espinoza who later arrived.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
LIC809 (FAS) - (06/04)
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