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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604128
Report Date: 02/09/2024
Date Signed: 02/09/2024 12:44:23 PM

Document Has Been Signed on 02/09/2024 12:44 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 THERAPEUTIC DAY PROGRAMFACILITY NUMBER:
374604128
ADMINISTRATOR:HEARD, DONNAFACILITY TYPE:
775
ADDRESS:970 LOS VALLECITOS BLVD #130TELEPHONE:
(760) 743-3714
CITY:SAN MARCOSSTATE: CAZIP CODE:
92069
CAPACITY: 50CENSUS: 10DATE:
02/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Healthcliff Moore, Program DirectorTIME COMPLETED:
12:50 PM
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Licensing Program Analyst(LPA) Javina George made an unannounced visit to the facility to conduct an annual inspection/1 year required visit. LPA was greeted and granted by Program Director Healthcliffe Moore, where LPA explained the purpose of the visit. The facility was observed to be clean, and clutter free. At the time of the visit there were seven (7) staff and zero (0) clients present. All staff were observed to have obtained criminal record clearance and to be associated to the facility.

LPA conducted a tour of the interior and exterior of the facility. As of 2/8/24, the facility is currently experiencing plumbing issues (clogged sewer pipe). LPA observed for the plumbers to be on site to correct the issue. Due to the plumbing challenges there were no in person services provided for the clients today. LPA was unable to check the temperature of the hot water. The projected completion date for repairs is by the end of business day today 2/9/24.

The facility is a single level suite with staff office's, Three (3) restrooms, an art room, computer lab, sensory room, Multipurpose room, kitchen and a garden,which contains plenty of space to sit as well as playground equipment. There were several activities and games to promote socialization, which includes exercise equipment, a swing and air hockey table.

The facility is conducting emergency disaster drills are conducted every six months as required. Drills were conducted on 10/18/23, on 1/30/24. The annual fire inspection was recently completed and no issues were reported. The carbon monoxide and smoke detectors were observed to be operable. The facility has two (2) fully charged fire extinguishers on the premises. The cleaning solutions and disinfectants were observed in a locked supply closet and were in accessible to clients. The medications are inaccessible also observed to be stored in a locked medication cart. The facility was observed to have an ample supply of Personal Protective Equipment (PPE).
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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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 THERAPEUTIC DAY PROGRAM
FACILITY NUMBER: 374604128
VISIT DATE: 02/09/2024
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There were no deficiencies observed during today's visit and the facility is operating in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 3).

An exit interview was conducted and a copy of this report and LIC 811 confidential name list was provided to Healthcliffe Moore Program Director.
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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