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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426867
Report Date: 10/09/2023
Date Signed: 10/09/2023 11:13:41 AM

Document Has Been Signed on 10/09/2023 11:13 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:HACIENDA CAREFACILITY NUMBER:
366426867
ADMINISTRATOR:CUSTODIO L. LAYGOFACILITY TYPE:
735
ADDRESS:13874 CHOCO RDTELEPHONE:
(760) 946-1041
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY: 6CENSUS: 6DATE:
10/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Custodio Laygo-AdministratorTIME COMPLETED:
11:17 AM
NARRATIVE
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On 10/09/23, Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with Staff Jason Laygo introduced self and stated purpose of the visit.

The facility has 4 bedrooms, 2 bathrooms, kitchen, dining, living room, activity room, laundry room, shed, 2 roofed storages and backyard. The facility is vendorized by Inland Regional Center. LPA completed a walk through of the facility, review of records and medication P&I audit.

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 73 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 missing lamp/light in a shared bedroom. Deficiency issued. LPA inspected client bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 114.9 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarm, charged fire extinguisher, and first aid kit. Posters such as; the personal rights, house rules and emergency disaster plan were posted in a common area. LPA observed that the Emergency Disaster Plan is outdated and not reviewed since 04/01/21. Deficiency issued. LPA observed that cleaning supplies, toxins, and medications were not kept locked and inaccessible to clients. Deficiency issued. Clients/Staff files and P&I were observed locked and made inaccessible. The facility had emergency kits and emergency water. There are no firearms, ammunition or bodies of water.

Yards/Outside: One shaded patio, a side gate with self-latching handle on the left side of the house that leads into the front yard, a shed and 2 roofed storages. All outdoor pathways were free of obstructions.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 10/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2023
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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Document Has Been Signed on 10/09/2023 11:13 AM - It Cannot Be Edited


Created By: Michelle Echeverria On 10/09/2023 at 10:31 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: HACIENDA CARE
FACILITY NUMBER: 366426867

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2023

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 administrator did not comply with the section cited above in maintaining chemicals and medication inaccessible to clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/09/2023
Plan of Correction
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Staff immediately locked closets where medication and chemicals were stored. Administrator stated that he will have a meeting training with staff and review regulation cited. Administrator will submit proof of attendance meeting to LPA via email by 10/16/23.
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: 10/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/09/2023 11:13 AM - It Cannot Be Edited


Created By: Michelle Echeverria On 10/09/2023 at 10:31 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: HACIENDA CARE
FACILITY NUMBER: 366426867

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(c)(2)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (2) Bedroom furniture including, in addition to (c)(1) above, for each client, a chair, a night stand, and a lamp or lights necessary for reading.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the administrator did not comply with the section cited above in replacing a lamp/light in the clients shared bedroom which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/16/2023
Plan of Correction
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Administrator stated that he will purchase a lamp/light for client's shared bedroom and submit a picture of receipt and lamp/light 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 and record review, the administrator did not comply with the section cited above in reviewing/updating the emergency disaster plan annually which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/16/2023
Plan of Correction
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Administrator stated that he will review/update the emergency disaster plan and submit a copy 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: 10/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2023


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: HACIENDA CARE
FACILITY NUMBER: 366426867
VISIT DATE: 10/09/2023
NARRATIVE
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Food Service: LPA observed 2 days of perishables and 7 days non-perishables food, pantry stocked and up to date. Dishes, cups, and utensils were stored properly.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPA reviewed clients files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed staff and administrator's files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. Medication and P& I was audited and matched with records.

Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D and appeal rights were discussed and copies were provided to Administrator, Custodio Laygo who later arrived.

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

DATE: 10/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023
LIC809 (FAS) - (06/04)
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