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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 371881367
Report Date: 03/18/2024
Date Signed: 03/18/2024 03:44:29 PM

Document Has Been Signed on 03/18/2024 03:44 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:AVID BEHAVIORAL DAY PROGRAM - CIVICFACILITY NUMBER:
371881367
ADMINISTRATOR:MAHARAJ, LORENAFACILITY TYPE:
775
ADDRESS:510 CIVIC CENTER DR SUITE ETELEPHONE:
(858) 442-6840
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY: 15CENSUS: 15DATE:
03/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Sarai Marcelin, COOTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to conduct an Annual Inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction and visit purpose. Upon arrival LPA learned that fifteen (15) clients are enrolled at this facility and there are currently six (6) staff. Clients were leaving for the day. The facility has an Infection Control Plan on file.

Personnel Records/Training/and Staffing- LPA began review of employee records. Five (5) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance, exemptions, transfer of a criminal record clearance, health screening and TB test results, (8) hours training verification, Administrator continuing education (30) hours every 24 months.

Client Records/Incident Reports/Personal Rights/Information- LPA began review of client records. Three (3) records were reviewed. LPA reviewed for admission agreement, needs and services plan, IPP, medical assessment and TB test results, identification and emergency information, client rights notification and register of clients.

Medications for three (3) participants are centrally stored. There is a locked cabinet allocated for medication storage. Medications reviewed appear to have been dispensed accurately however one (1) pill was observed in a baggie with clients name on it and medications are not being destructed.

Due to time constraint, LPA will need to return to complete the inspection. (Continued page 2)
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2024
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 03/18/2024 03:44 PM - It Cannot Be Edited


Created By: Yolanda Delgado On 03/18/2024 at 03:16 PM
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: AVID BEHAVIORAL DAY PROGRAM - CIVIC
FACILITY NUMBER: 371881367

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
82075
82075 Health-Related Services (l) The following requirements shall apply to medications which are centrally stored: (5) Each client's medicaton shall be storedin its originally received container.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in which Client #1 (C1)'s centrally stored medications were observed in a clear case and one white pill was observed inside a clear sandwich baggie with C1's name written across the top of the bag in a black marker which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/19/2024
Plan of Correction
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Licensee will do in-service training with staff and submit proof of training to LPA via email by POC due date.
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:Jazmond D Harris
LICENSING EVALUATOR NAME:Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2024


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
RIVERSIDE, CA 92507
FACILITY NAME: AVID BEHAVIORAL DAY PROGRAM - CIVIC
FACILITY NUMBER: 371881367
VISIT DATE: 03/18/2024
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(Continued from page 1)

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

This LIC 809, 809-C , 809D and Appeal Rights was reviewed with and a copy provided to the facility representative.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024
LIC809 (FAS) - (06/04)
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