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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425780
Report Date: 08/15/2023
Date Signed: 08/15/2023 09:22:13 AM

Document Has Been Signed on 08/15/2023 09:22 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:SPECIALIZED RESIDENTIAL LUPINEFACILITY NUMBER:
366425780
ADMINISTRATOR:LAWANNA JONESFACILITY TYPE:
735
ADDRESS:22334 LUPINE RDTELEPHONE:
(760) 247-2391
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92308
CAPACITY: 4CENSUS: 4DATE:
08/15/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:07 AM
MET WITH:LaWanna Jones, AdministratorTIME COMPLETED:
09:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Rayshaun Nickolas met with Administrator LaWanna Jones in the Riverside/San Bernardino Regional Office for a case management-deficiency visit.

While investigating complaint control number 56-AS-20230731160443, LPA Nickolas discovered that staff #1 (S1) admitted to yelling at resident #1 (R1) on Thanksgiving Day.

Based on the information provided, one (1) deficiency was cited per Title 22, Division 6, of the California Code of Regulations (CCR). An exit interview was conducted, and a copy of this report (LIC 809), LIC 809D, and Appeal Rights were provided.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2023
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 2
Document Has Been Signed on 08/15/2023 09:22 AM - It Cannot Be Edited


Created By: Rayshaun Nickolas On 08/15/2023 at 08:05 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
, CA 92507

FACILITY NAME: SPECIALIZED RESIDENTIAL LUPINE
FACILITY NUMBER: 366425780

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/08/2023
Section Cited
CCR
80072

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80072 Personal Rights
(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:
(1) To be accorded dignity in his/her personal relationships with staff and other persons...
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The Licensee shall ensure the entire cited section of regulation is read and provide training to all staff. Licensee shall also submit proof of training, with staff signatures, to the Regional Office (RO) by the POC due date..
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This requirement was not met, as evidenced by the following:
Based on interview, staff #1 (S1) admitted to yelling at resident #1 (R1), which posed a health, safety, and personal rights violations to persons in care.
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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:Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2023


LIC809 (FAS) - (06/04)
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