372008333-9-7-2023-18-AS-CGOH-CVFSC3-20230907134451

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 372008333
Report Date: 08/25/2023
Date Signed: 09/07/2023 01:45:06 PM

Document Has Been Signed on 09/07/2023 01:45 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:	DOWNSTOWN, INC. V		FACILITY NUMBER:	372008333
ADMINISTRATOR:	KECIA STINNETT		FACILITY TYPE:	735
ADDRESS:	1089 JENNIFER CIRCLE		TELEPHONE:	(760) 630-0028
CITY:	VISTA	STATE: CA	ZIP CODE:	92083
CAPACITY: 4		CENSUS: 4	DATE:	08/25/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:27 AM
MET WITH:	Kecia Stinnett, Executive Director		TIME COMPLETED:	01:47 PM

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	On 09/07/23 at 11:27 Licensing Program Analyst (LPA) Cheryl Goodrich arrived to conduct an unannounced annual visit. LPA met Kecia Stinnett, Executive Director and Elissa Ciaverelli, Administrator at the front door and was granted entry. The purpose of today’s visit is to inspect the facility to ensure that the facility is following California Code of Regulations, Title 22, Division 6. Facility is approved for four (4) ambulatory residents, having 3 residents in care. There are no residents at the facility during the inspection due to being at day program. Infection Control: The facility has an approved infection control plan and a surplus of supplies for infection control including but not limited to mask, gloves, gowns, first aid kit, protective eye equipment and cleaning supplies. Physical Plant and Environmental Safety: There are a total of 3 resident bedrooms, and 2 bathrooms, a kitchen, living room, backyard area with furniture for residents and staff. All rooms, living room, laundry area, kitchen, dining room are all clean and clear of obstruction. The resident bedrooms were clean and clear from obstruction. The resident’s rooms were complete with clean linens and bedding, dresser, and closet space. There is a pool that is fenced in a meet’s regulation requirements, and is locked. Operational Requirements: The facility was staffed with 1 caregiver. The facility meets the operational requirements for an AR and has a current fire clearance for the facility, smoke and carbon monoxide detectors and fire extinguishers. Personnel Records-Training: All staff have fingerprint clearances, current CPR/First Aid certification, Health screen and TB test completed. All staff complete monthly in-service training and fire-drills and disaster training. (Continued on LIC809-C)

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Cheryl Goodrich
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023

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: DOWNSTOWN, INC. V	FACILITY NUMBER: 372008333
	VISIT DATE: 08/25/2023

NARRATIVE

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(Continued from LIC809)

Client Rights-Information: The resident’s right documentation is present. The resident records also contain needs assessment information for each resident.
Food Service: 7-day non-perishable and 2 day of perishable food supply was observed, and all food was properly stored and available to residents.
Health- Related Services: The caregiver at the facility are dispensing medications within the guidelines of the physician’s order and the regulations. The facility is documenting the date and time of the dispensing of medication for each resident.
Disaster Preparedness: The facility has a disaster plan and has posted the evacuation plan, visible for staff and residents in care. The last fire drill was completed 07/05/23. The facility has emergency supply of food and water.
Items reviewed/discussed: The facility handles the resident’s cash resources, however none of the cash resource documentation or cash is present at the facility due to weekly audit, therefore a deficiency is being cited.
Summary: A deficiency is being cited per Title 22, Div. 6, Chap 8 and listed on LIC 809-D. An exit interview was conducted, Appeal Rights (LIC 9098) along with a copy of this report was provided to Kecia Stinnett, Executive Director and her signature on this form confirms receipt of these rights.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Cheryl Goodrich
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/07/2023 01:45 PM - It Cannot Be Edited

Created By: Cheryl Goodrich On 09/07/2023 at 01:28 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: DOWNSTOWN, INC. V	FACILITY NUMBER: 372008333
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80026(j)

Safeguards for Cash Resources, Personal Property and Valuables

(j) Cash resources entrusted to the licensee and kept on the facility premises, shall be kept in a locked and secure location. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on review of the resident records and discussion with the Executive Director, the licensee did not comply with the section cited above in 3 out of 3 resident cash resources and cash resource documentation which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/15/2023
	Plan of Correction
1 2 3 4	The Executive Director of facility agrees to provide the Department with documentation of budget sheets, envelopes, PI receipts and proof of ledger in the safe.

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

LICENSING EVALUATOR NAME:

Cheryl Goodrich

LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

LIC809 (FAS) - (06/04)

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