<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604135
Report Date: 04/25/2023
Date Signed: 04/25/2023 01:22:40 PM


Document Has Been Signed on 04/25/2023 01:22 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:SHADOWRIDGEFACILITY NUMBER:
374604135
ADMINISTRATOR:BEATRICE BRACAMONTEFACILITY TYPE:
740
ADDRESS:2354 WATSON WAYTELEPHONE:
(760) 295-3888
CITY:VISTASTATE: CAZIP CODE:
92081
CAPACITY:48CENSUS: 37DATE:
04/25/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Veronica Delval, LVNTIME COMPLETED:
01:35 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 4/25/2023, Licensing Program Analysts (LPAs) Chinwe Nwogene and Janette Romero arrived unannounced to the facility to conduct a case management visit regarding a staff taking money from residents. LPA met with LVN, Veronica Delval who was informed of the purpose of the visit.

During the visit, LPAs interviewed staff and residents. It was acknowledged that the identified staff has taken money from resident #1 numerous times. LPA interviewed Executive Director, Levina Dubose who stated the staff was terminated on 4/19/2023. Levina stated there is a section in the program plan that addresses staff accepting gifts from residents and staff are aware not to take money from residents. A citation will be issued.

Therefore, based on the interview made during today’s visit, one #1 citation will be issued per Title 22, Division 6 of the California Code of Regulations. See LIC 809D. An exit interview was conducted, and this reported was reviewed with and provided along with appeal rights to Veronica Delval.

SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Chinwe NwogeneTELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2023
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 04/25/2023 01:22 PM - It Cannot Be Edited

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: SHADOWRIDGE
FACILITY NUMBER: 374604135

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
04/26/2023
Section Cited
CCR
87468.2(8)

1
2
3
4
5
6
7
Additional Personal Rights of Residents in Privately Operated Facilities;

To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse.
1
2
3
4
5
6
7
Executive Director, stated a proof of training and policy addressing staff taking money and gifts from residents will be provided to LPA by POC due date 4/26/2023.
8
9
10
11
12
13
14
This requirement is not met based as evidence by interview. The licensee did not comply by having a staff take money from residents which poses a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Chinwe NwogeneTELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2