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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425780
Report Date: 09/16/2024
Date Signed: 09/16/2024 11:47:59 AM

Document Has Been Signed on 09/16/2024 11:47 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:SPECIALIZED RESIDENTIAL LUPINEFACILITY NUMBER:
366425780
ADMINISTRATOR/
DIRECTOR:		LAWANNA JONESFACILITY TYPE:
735
ADDRESS:22334 LUPINE RDTELEPHONE:
(760) 247-2391
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92308
CAPACITY: 4CENSUS: 4DATE:
09/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Rasheena RossTIME VISIT/
INSPECTION COMPLETED:
11:55 AM
NARRATIVE
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Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with House Lead, Rasheena Ross, and discussed the purpose of the visit.

The facility is an Adult Residential facility with a license capacity of (4) and a current census (4). LPA conducted an overall inspection, which included, but was not limited to, the following:

Operation/Physical Plant: Indoor and outdoor passageways were kept free of obstruction. The facility has no swimming pools or similar bodies of water. The facility has sufficient indoor and outdoor activity space for clients in care. The facility is equipped with smoke/carbon monoxide alarms, laundry equipment, bed linen, towels and telephone service. Client bedrooms were equipped with beds, bed linen, nightstands, chairs, storage space and bedroom lighting. Client bathroom equipment was operating in safe conditions. The hot water in client bathrooms tested at 109 degrees F. Sharps and cleaning supplies were store in a locked cabinet. The facility has posted: facility license, evacuation plan, client personal rights and planned activities. The Administrator's certification and facility's insurance is current.

Care and Supervision: The facility has 24 hours, 7 days a week care staff.

Food Service: The facility’s kitchen area was maintained clean. The facility has sufficient non-perishable and perishable food for number of clients in care.

Health Related Services: The facility maintains records of client medications and medications are centrally stored in a locked cabinet.

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Magda Malcore
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2024
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: SPECIALIZED RESIDENTIAL LUPINE
FACILITY NUMBER: 366425780
VISIT DATE: 09/16/2024
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Personnel/Client Record: Client records were reviewed for admission agreements, medical assessments, needs and service plans. LPA did not review client's personal & incidental logs (P&I) due to current staff not having access to the records and funds. Deficiency cited. Staff files were reviewed for health screenings, applications, criminal record clearances, first aid/CPR training certifications, and training. LPA's review of staff's health screenings reveals, staff #1 (S1) did not have tuberculosis results and clearance on file. Deficiency cited.

Based on LPA's observations and record review, deficiencies are being cited in accordance with Title 22, division 6, of the California Code of Regulations. An exit interview was conducted, where this report was discussed and a copy with appeal rights was provided to the House Lead, at the conclusion of the visit.

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Magda Malcore
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/16/2024 11:47 AM - It Cannot Be Edited


Created By: Magda Malcore On 09/16/2024 at 11:17 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: SPECIALIZED RESIDENTIAL LUPINE
FACILITY NUMBER: 366425780

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type B
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observations, the licensee did not comply with the section cited above by not maintaining record of staff #1 (S1's) tuberculosis results & clearance; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/01/2024
Plan of Correction
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The Licensee/Administrator shall submit to the licensing agency documentation of staff's tuberculosis clearance by POC due date.
Request Denied
Type B
Section Cited
CCR
80070(d)
Client Records
(d) All client records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observations, the licensee did not comply with the section cited above by current staff not having access to client P&I ledgers and funds for LPA to review; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/01/2024
Plan of Correction
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The Licensee/Administrator shall submit a statement of understanding on the regulation cited and submit to the licensing agency 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: 09/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2024


LIC809 (FAS) - (06/04)
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