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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603572
Report Date: 12/08/2023
Date Signed: 12/08/2023 03:22:25 PM

Document Has Been Signed on 12/08/2023 03:22 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:AVID BEHAVIORAL DAY PROGRAMFACILITY NUMBER:
374603572
ADMINISTRATOR:SARAI MARCELINFACILITY TYPE:
775
ADDRESS:562 W GRAND AVENUETELEPHONE:
(442) 999-5740
CITY:ESCONDIDOSTATE: CAZIP CODE:
92025
CAPACITY: 60CENSUS: 55DATE:
12/08/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Licensee, Sarai MarcelinTIME COMPLETED:
03:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola made an unannounced visit to the facility in order to conduct a case management. LPA met with Licensee, Sarai Marcelin who was informed of the purpose of the visit.

LPA conducted a health and safety check of the residents in care. During the time of the the participants were getting picked up from their day program. LPA conducted interviews, gathered documents and conducted a walk through of the facility. LPA found unlocked chemicals in the broom closet in the kitchen, and found unlabeled medication in a kitchen drawer that was unlocked. LPA had staff lock and secure items immediately. Deficiency will be cited and plan of correction was documented with licensee.

At this time the department will evaluate information gathered on incident report. Additional visits or phone calls may be necessary. Licensee was informed of the documents that would need to be sent to the LPA to their email and documented on technical note.

An exit interview was conducted with Licensee, Sarai Marcelin where this report along with LIC809-D, and appeal rights were reviewed and provided to them.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 12/08/2023 03:22 PM - It Cannot Be Edited


Created By: Janira Arreola On 12/08/2023 at 02:22 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
FACILITY NUMBER: 374603572

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/09/2023
Section Cited
CCR
82087(a)(3)

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82087 Buildings and Grounds (a)The program site shall be...safe..(3)...cleaning solutions...and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
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The licensee agreed to send the LPA a letter by POC due date on in-service to be held on 12/11/23, and material to be covered. In-service shall address locking of chemicals,
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This requirment was not met as evidenced by: LPA observed unlocked cleaning supplies and unlocked medication at the facility. This poses an immediate health safety or personal rights risk.
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and ensuring staff and resident medications are kept locked. Staff sign in sheet will be sent to LPA showing the in-service was completed.

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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:Rikesha Stamps
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2023


LIC809 (FAS) - (06/04)
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