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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426281
Report Date: 09/27/2022
Date Signed: 09/27/2022 11:01:04 AM


Document Has Been Signed on 09/27/2022 11:01 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:TERRACE GARDENSFACILITY NUMBER:
366426281
ADMINISTRATOR:MAWIKERE, DEKKIFACILITY TYPE:
740
ADDRESS:22626 FLAMINGO ST.TELEPHONE:
(909) 824-8126
CITY:GRAND TERRACESTATE: CAZIP CODE:
92313
CAPACITY:6CENSUS: 5DATE:
09/27/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:02 AM
MET WITH:Dekki MawikereTIME COMPLETED:
11:05 AM
NARRATIVE
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to this facility to verify a proof of correction from an 8/16/2022 visit citation and to deliver an amended report of complaint control number: 56-AS-20220808090401.

Complaint control number 56-AS-20220808090401 is SUBSTANTIATED and deficiency is being cited on this report's LIC809-D.

LPA Bueno verified that the side gates are accessible from the outside and LPA viewed Resident 1's physician's order for PRN medications. A Letter of Deficiency Citations Cleared was issued to Administrator Mawikere on this day.

Administrator Mawikere signed the amended LIC9099, LIC809, and LIC809-D. All reports, including aforementioned forms, appeal rights , and letter of deficiency citation cleared, were discussed with and copies were provided to Mr. Mawikere at the conclusion of today’s visit.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2022
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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Document Has Been Signed on 09/27/2022 11:01 AM - It Cannot Be Edited

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: TERRACE GARDENS
FACILITY NUMBER: 366426281

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/10/2022
Section Cited

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Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials.

This requirement is not met as evidenced by:
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As indicated on complaint number 56-AS-20220808090401, Resident 1 was found outside the facility and returned to this facility by a visitor.
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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 BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2022
LIC809 (FAS) - (06/04)
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