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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604135
Report Date: 10/26/2022
Date Signed: 10/26/2022 02:58:11 PM


Document Has Been Signed on 10/26/2022 02:58 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:
10/26/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:17 AM
MET WITH:Executive Director, Bree LofvendahlTIME COMPLETED:
03:15 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 visit for deficiencies observed. LPA met with Nurse, Veronica Delval who was informed of the purpose of the visit.

LPA conducted a walk through of the interior and exterior of the facility. LPA found the following deficiencies:
  • LPA found that the current administrator on file is not the current administrator at the facility. LPA will cite for failure to inform the department within 30 days of the administrator change. This poses a potential risk for residents in care. LAP will document deficiency and plan of correction for this.
  • LPA noted that the facility laundry room had an open door with open powdered laundry detergent close to the door. LPA observed a resident in a wheelchair in the vicinity. LPA was informed by the nurse that staff usually leave the door unlocked as they come and go. This poses an immediate risk to residents in care. LPA will document deficiency and plan of correction for this.


An exit interview was conducted and a copy of this report, along with LIC809-D pages, and appeal rights were reviewed and provided to Executive Director Bree Lofvendahl.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2022
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 10/26/2022 02:58 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: 10/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/27/2022
Section Cited

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87309Storage Space (a) Disinfectants, cleaning solutions... other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.
This requirment was not met as evidenced by:
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LPA observed the facility laundry room door was left open and accessible to residents in the outdoor area. LPA also spoke with staff who stated that staff come and go and do not always secure the door. Thsi poses an immediate health, saftey or personal rights risk.
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Type B
11/04/2022
Section Cited

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87211 Reporting Requirements
(g) The licensee shall notify the Department, in writing, within thirty (30) days of the hiring of a new administrator....
This requirment was not met as evidenced by:
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LPA observed the listed administrator is not the active administrator at the facility. LPA spoke with the adminsitrator who stated that they were unsure if this information was sent to the regional office. This poses a potential health, saftey, or personal rights risk for 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: 10/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2022
LIC809 (FAS) - (06/04)
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