374603352-5-26-2023-18-AS-JARA-CS7SQ6-20230526140413

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603352
Report Date: 05/26/2023
Date Signed: 05/26/2023 02:04:56 PM

Document Has Been Signed on 05/26/2023 02:04 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:	MOUNTAIN SHADOWS OUTREACH SERVICES		FACILITY NUMBER:	374603352
ADMINISTRATOR:	FLOR ANGEL REAL		FACILITY TYPE:	775
ADDRESS:	970 LOS VALLECITOS BLVD, 140		TELEPHONE:	(760) 743-3714
CITY:	SAN MARCOS	STATE: CA	ZIP CODE:	92069
CAPACITY: 150		CENSUS: 30	DATE:	05/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Administrator, Flor Angel Real		TIME COMPLETED:	02:15 PM

NARRATIVE

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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit on 5/26/2023 at 11:26 a.m. LPA was granted entry and met with Administrator, Flor Angel Real, who was informed of the purpose of the visit. At the time of the visit there were (30) client present.

The facility is a adult day program. It is a one story building with (3) common activity rooms, (2) bathrooms, (4) personal care rooms for changing clients, (4) activity rooms, and (1) kitchen/staff lounge. The facility provides snacks to clients. No pools or firearms are being kept at the facility. The facility does not have an outdoor space The clients served are adults between the ages of 18-59. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted a staff and client interviews. LPA observed the following:

Infection Control: The LPA observed the hand washing stations in the facility restrooms. Hand hygiene supplies and hand washing signs were observed. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements. LPA reviewed staff records and found that all staff had infection control training.

Physical Plant: LPA observed the interior and exterior. Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. Laundry equipment was observed to be in working condition. LPA observed kitchen knifes were in an unlocked cabinet in kitchen area. LPA also observed unlocked scissors on staff desks in common activity room, and observed unlocked unsupervised scissors in a client activity room. Deficiency was cited for this along with plan of correction. The smoke detector and carbon monoxide are operational, and the hot water temperature 106.7F.

Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in working condition. LPA reviewed the facilities admission agreement and found that the facility provides snacks.

Care & Supervision/Administration: Adequate staff are present for the supervision of clients during the visit. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The listed administrator, possesses the required hours of continuing education and experience required.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023

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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MOUNTAIN SHADOWS OUTREACH SERVICES	FACILITY NUMBER: 374603352
	VISIT DATE: 05/26/2023

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Record Review and Resident/Staff Files: LPA reviewed (3) staff files and training. All staff have criminal clearance and updated training along with CPR/First Aid Certification. Two (3) client files were reviewed, and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: All client medication was locked in a medication cart.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan which met the department requirements. LPA reviewed documentation showing the facility's last fire and earthquake drills, which was conducted April of 2023. LPA observed all facility exits were clear from obstructions. LPA observed first aid kit with all required items.

An exit interview was conducted where this report along with deficiency pages and appeal rights were reviewed and provided to the Administrator, Flor Angel Real.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/26/2023 02:04 PM - It Cannot Be Edited

Created By: Janira Arreola On 05/26/2023 at 01:50 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: MOUNTAIN SHADOWS OUTREACH SERVICES	FACILITY NUMBER: 374603352
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

82087(a)(3)(A)

Buildings and Grounds

(a) The program site shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (3) Disinfectants, cleaning solutions, poisons, and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (A) Storage areas for poisons shall be locked. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview), the licensee did not comply with the section cited above with kitchen knifes and office sissors that were found unlocked and accessible to clients in facility kitchen area, staff desks and activity rooms. The maintence staff installed a lock for the kitchen knifes by the end of the visit. This which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/27/2023
	Plan of Correction
1 2 3 4	The licensee agreed to lock all dangerous objects and send the LPA a signed statement stating when this had been completed. They must send the LPA ohotos of this being completed and the statement by the POC due date.

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:

Joel Esquivel

LICENSING EVALUATOR NAME:

Janira Arreola

LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023

LIC809 (FAS) - (06/04)

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