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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 372008467
Report Date: 02/09/2024
Date Signed: 02/09/2024 04:16:09 PM

Document Has Been Signed on 02/09/2024 04:16 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:DOWNSTOWN IVFACILITY NUMBER:
372008467
ADMINISTRATOR:SUSAN LAUBACHFACILITY TYPE:
735
ADDRESS:1710 REES ROADTELEPHONE:
(760) 746-2111
CITY:SAN MARCOSSTATE: CAZIP CODE:
92069
CAPACITY: 6CENSUS: 4DATE:
02/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Angela Ramirez, House ManagerTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct an annual inspection. LPA was greeted and granted entry by House Manager Angela Ramirez, where LPA explained the purpose of the visit. The Administrator arrived shortly after. At the time of the visit there was one (1) staff and four (4) resident's present. The facility serves six (6) developmentally disabled clients, ages 18-59, all of whom are ambulatory.

LPA conducted a tour of the interior and exterior of the facility, All passageways were free from obstruction. There are no pools or bodies of water on the premises. The facility was observed to be clean, clutter and odor free. LPA observed for there to be a total of three (3) sheds that are used for storage inside the backyard. The facility was observed to have a sufficient food supply which consisted of a 2 day supply of perishable and a 7 day supply of nonperishable food items.

The facility was observed to have a fully charged fire extinguisher with a current tag. Smoke detectors and a carbon monoxide detectors were tested and observed to be operable. LPA conducted a review of the facility emergency disaster drills the facility was observed to be out of compliance as the last fire drill was conducted on 4/19/22. Drills are to be conducted on a quarterly basis. A citation will be issued in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 6). and can be found on the attached 809D. The hot water temperature in both bathrooms was measured and was observed to be within regulatory limits ranging from 116-117 degrees Fahrenheit.

Disinfectants, cleaning solutions, poisons, and sharp objects were locked and inaccessible to clients in care.
Medications are stored in a locked cabinet and administered according to the label instructions.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2024
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 02/09/2024 04:16 PM - It Cannot Be Edited


Created By: Javina George On 02/09/2024 at 03:49 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 IV
FACILITY NUMBER: 372008467

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 1 times, as the last drill was conucted on 4/19/22, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/10/2024
Plan of Correction
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The licensee agrees to conduct a disaster drill and proof of correction is to be submitted by 5pm on the due date indicated.
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:Javina George
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2024


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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: DOWNSTOWN IV
FACILITY NUMBER: 372008467
VISIT DATE: 02/09/2024
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The facility was observed to have the required postings. The facility currently has a section of the ceiling in the kitchen removed, as there was a leak from the recent storm this weak, a quote was received as the roof has to be rebuilt from the frame.

An exit interview was conducted and a copy of this report and appeal rights were provided to Angela Ramirez, House Manger
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024
LIC809 (FAS) - (06/04)
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