371881350-6-24-2023-18-AS-JSRS-CT56BZ-20230624204046

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 371881350
Report Date: 06/24/2023
Date Signed: 06/24/2023 08:40:51 PM

Document Has Been Signed on 06/24/2023 08:40 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	CORAL TREE CARE		FACILITY NUMBER:	371881350
ADMINISTRATOR:	MORRISON, VAL M		FACILITY TYPE:	740
ADDRESS:	3549 HOLLYBERRY DRIVE		TELEPHONE:	(310) 733-6727
CITY:	VISTA	STATE: CA	ZIP CODE:	92084
CAPACITY:	6	CENSUS: 6	DATE:	06/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Val Morrison, Administrator		TIME COMPLETED:	08:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) Jacqueline Shaw Ross conducted an unannounced annual required visit on 6/24/2023 at 3:15 p.m. LPA was granted entry by Administrator Val Morrison who was informed of the purpose of the visit. At the time of the visit there were six (6) clients and two (2) staff present. The home is licensed to provide care to six (6) non-ambulatory clients, with an approved hospice waiver for three(3). The facility is a one story home with five (5) bedrooms and (3) bathrooms. LPA observed the following:

Physical Plant: LPA observed for required accommodations in resident bedrooms and bathrooms. Physical plant, floors, windows, and doors are clean. Fixtures and furniture for an operational facility are present and in good repair. There is an adequate number of bedrooms present for the requested number of residents. Chemicals were observed locked in designated areas in the facility. Alarm system was tested and operational. Fire extinguishers are fully charged. Emergency drills are conducted regularly.

Kitchen/Food Service: LPA observed food service area had the ability to serve food and cleanliness. Food supply was checked and met the requirement for a two day supply of perishable food and seven days of non-perishable food. Dishes, utensils, glasses are present.

Care & Supervision/Administration: Adequate staff are present for the supervision of residents. Emergency exiting plans, telephone numbers and personal rights were found posted in the facility.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2023

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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CORAL TREE CARE	FACILITY NUMBER: 371881350
	VISIT DATE: 06/24/2023

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Record Review and Resident/Staff Files: Staff and client record reviews were conducted. During LPAs visit, and per records review, (S1) was observed to not be associated to the facility and has been working as a caregiver for the facility since June 3, 2023. (S1) is the daughter of one of the Administrators' and is in the process of obtaining background clearance. LPA observed (S1) being escorted off the premises. LPA informed Administrator that (S1) cannot return until clearance is verified.

A Civil Penalty of $100/day will apply for a total of $500 for five (5) days.
The following violation is cited under Title 22 section 87355(e)(2). Deficiency cited.

The following additional observation was noted:
LPA noted that the facility has a bedroom that is being used as a passage way to a walk in closet that was converted to a small staff office. LPA observed a small desk, chair and small cot. Deficiency was not cited, as this was corrected at the time of LPAs visit.

An exit interview was conducted where this report along with (LIC809), (LIC809C), LIC809D, LIC421BG and Appeal Rights were discussed and provided to Administrator, Val Morrison.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/24/2023 08:40 PM - 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CORAL TREE CARE	FACILITY NUMBER: 371881350
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(2)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [1] out of [1] times licensee failed to insure that S1 obtained fingerprint clearance before working at the facility. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/26/2023
	Plan of Correction
1 2 3 4	Licensee agrees to associate S1 in Guardian by 5:00pm on the due date indicated.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2023

LIC809 (FAS) - (06/04)

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