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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604135
Report Date: 12/12/2022
Date Signed: 12/12/2022 02:30:33 PM


Document Has Been Signed on 12/12/2022 02:30 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: 36DATE:
12/12/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Staff, Levina DuboseTIME COMPLETED:
02:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit on 12/12/2022 at 10:00 a.m. in order to cite for deficiencies observed. LPA met with staff, Levina Dubose, who was informed of the purpose of the visit.

LPA requested a copy of the facility menu, and staff Levina informed LPA that the current cook in charge of the menu was out and was unable to locate the menu during the time of the visit. Staff was able to provide the LPA will a pre-planned menu for the week but unable to provide the menu for the month. This is a violation of California Code of Regulations Title 22. The deficiency was documented on an LIC 809-D page along with the plan of correction.

LPA asked to review the staff, Levina Dubose file and was informed that the file would be emailed to LPA as it was not physically at the facility. LPA will issue a technical advisory note for this and advised facility to have file readily available for timely review and have file emailed by the end of the day.

An exit interview was conducted where this report was reviewed along with LIC809-D page and appeal rights. These reports were provided to staff, Levina Dubose.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2022
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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Document Has Been Signed on 12/12/2022 02:30 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: 12/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/12/2023
Section Cited

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87555 General Food Service Requirements (b)The following food service requirements shall apply:(6)In facilities for sixteen (16) persons or more...copies of the menus as served shall be dated and kept on file for at least 30 days...Menus shall be made available for review by...the licensing agency...
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The licensee shall send LPA a copy of the menu for the month of Decmber by the POC due date and ensure at least (30) menu is kept date and available for review at the fcaility.
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This requirment was not met as evidenced by:
LPA requested to review the menu for the month of December. Staff stated the menu was not available to review for the month or (30) day period. Thsi poses a potential health, saftey, or personal rights risk to residents in care.
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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: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2022
LIC809 (FAS) - (06/04)
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