366426281-11-30-2023-56-AS-AGOG-CY3R2M-20231130113835

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366426281
Report Date: 11/30/2023
Date Signed: 11/30/2023 11:39:22 AM

Document Has Been Signed on 11/30/2023 11:39 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 GARDENS		FACILITY NUMBER:	366426281
ADMINISTRATOR:	MAWIKERE, DEKKI		FACILITY TYPE:	740
ADDRESS:	22626 FLAMINGO ST.		TELEPHONE:	(909) 824-8126
CITY:	GRAND TERRACE	STATE: CA	ZIP CODE:	92313
CAPACITY:	6	CENSUS: 6	DATE:	11/30/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	Dekki Marikere, Administrator		TIME COMPLETED:	11:45 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	0855: Licensing Program Analyst (LPA) Amy Goldenberg arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction, visit purpose of the visit. LPA toured the facility inside and outside. LPAs observe the facility to be clean and in good repair. The home is maintained at a comfortable temperature for the residents. Lighting is sufficient for safety and comfort. Water temperature measured 110.2 degrees F. Grab bars, non slip mats are present in the restrooms. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals. All outdoor and indoor passageways were inspected. Night lights and emergency lighting is present. A locked area is provided for medications and sharp objects. There is a telephone working at this location. The LIC 610E, emergency disaster plan is maintained. The facility has a current written definitive plan of operation. The facility does not handle resident money. Six (6) records were reviewed. LPA reviewed for admission agreement, medical assessment and TB test results, consent forms, identification and emergency information, appraisal needs and service plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. Resident Rights are posted in the facility and a copy is signed on file. Food prep areas are clean and organized. Food supply meets the requirement of one week supply of nonperishable and 2 day supply of perishables food on hand.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023

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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: TERRACE GARDENS	FACILITY NUMBER: 366426281
	VISIT DATE: 11/30/2023

NARRATIVE

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LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. LPA observed two gates leading from the back yard with locking mechanisms which prevent exiting without a key. LPA observed that the key is maintained in a coded lock box on the side of a backyard shed with the key in it. LPA also observed in the garage an addition of walls and a door. Inside the addition is a bed, clothing and personal effects of caregivers. Administrator admits that they are using the space place to rest for the employees. This space is not part of the approved fire clearance as a caregiver room. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguishers are tested or replaced annually, last done 5/24/2023 . The facility is conducting emergency disaster drills, last done on 06/03/2023. LPA observed a camera in one of four resident bedrooms.

Based on the information received during this visit today, the following deficiencies are being cited per Title 22, Division 6 of The California Code of Regulations.

This report was reviewed with and a copy provided to the facility representative. Appeal Rights were also provided at the time of the exit interview.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/30/2023 11:39 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: 11/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on the following: LPA observed two gates leading from the back yard with locking mechanisms which prevent exiting without a key. LPA observed that the key is maintained in a coded lock box on the side of a backyard shed with the key in it. LPA also observed in the garage an addition of walls and a door. Inside the addition is a bed, clothing and personal effects of caregivers. Administrator admits that they are using the place a a place to rest for the employees. This space is not part of the approved fire clearance as a caregiver room.
	POC Due Date: 12/01/2023
	Plan of Correction
1 2 3 4	Licensee to cease utilizing a locked perimeter by removing any locking device designed to lock individuals on the premesis. In addition licensee to submit LIC 200 to obtain approval to utilize the space in the garage as a living quarters for employees or only use that space for storage. Bed to be removed from the space.

Type A

Section Cited

CCR

87468.2(a)(1)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation of cameras in the bedrooms. This is a violation of the residents personal rights.
	POC Due Date: 12/01/2023
	Plan of Correction
1 2 3 4	Licensee to immediately remove all cameras from all areas of the facility where resident care is provided and could be observed with a camera. Licensee must put an addendum post for public view the use of cameras in the facility in common areas.

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	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023

LIC809 (FAS) - (06/04)

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