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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603352
Report Date: 05/06/2024
Date Signed: 05/06/2024 03:46:16 PM

Document Has Been Signed on 05/06/2024 03:46 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:MOUNTAIN SHADOWS OUTREACH SERVICESFACILITY NUMBER:
374603352
ADMINISTRATOR/
DIRECTOR:		FLOR ANGEL REALFACILITY TYPE:
775
ADDRESS:970 LOS VALLECITOS BLVD, 140TELEPHONE:
(760) 743-3714
CITY:SAN MARCOSSTATE: CAZIP CODE:
92069
CAPACITY: 150CENSUS: 48DATE:
05/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:56 PM
MET WITH:Flor Angel Real, Program DirectorTIME VISIT/
INSPECTION COMPLETED:
03:55 PM
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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct a 1 year required visit. LPA was greeted and granted entry by Program Director Flor Angel Real where LPA explained the purpose of the visit. At the time of LPAs visit there was (48) clients and (28) staff. The ratio is 3:1. LPA observed for all staff to have obtained criminal record clearance and to be associated to the facility. Below are the observations made from today's visit:

LPA conducted a tour of the interior and exterior of the facility. The facility is a single level suite consisting of a music room, art room, (4) personal care rooms, nurse's office, kitchen and (4) activity rooms. There are 2 bathrooms for the clients to use, the clients bring their lunches from home, and the program provides snack that is followed by a weekly schedule. The facility mitigation plan is on file dated 1/22/21.

The smoke and carbon monoxide detectors were tested by a local contractor and all parts connected to the detectors were operable and found to be in good repair. The emergency disaster drills are being conducted on a monthly basis, and the last drill conducted was on 4/30/24. The fire extinguishers are fully charged and were recently inspected on 4/19/24. There are no known guns or ammunition on the premises. The medications are locked inside a medication cart that is stored inside the Nurse's office. There are no pools or bodies of water on the premises. The sharps are locked in a cabinet in the kitchen underneath the sink. The scissors or shears are stored in a locked drawer below the counter where the microwave oven sits. The hot water was tested and measured at 108.8 degrees F.

The facility was observed to have the required postings such as emergency disaster plan, personal rights, license, facility sketch and CCL complaint poster (PUB475). The chemicals are stored a locked cabinet underneath the kitchen sink as well as in a locked closet, inside the big room by the supervisor's office.

Both client and staff files were reviewed and the facility uses an electronic program called Therap.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2024
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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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: MOUNTAIN SHADOWS OUTREACH SERVICES
FACILITY NUMBER: 374603352
VISIT DATE: 05/06/2024
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LPA reviewed (3) client files with Program Director Flor, all clients were observed to have the required documentation such as IPP/appraisals, medical assessments and admissions agreements. Five (5) staff files were reviewed and were found to have all the required documentation with training and valid Cardio Pulmonary Resuscitation (CPR) certificates.

Based on today's inspection there were deficiencies issued.

An exit interview was conducted and a copy of this report was provided to Flor Angel Real, Program Director.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024
LIC809 (FAS) - (06/04)
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