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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604207
Report Date: 06/19/2024
Date Signed: 06/19/2024 05:17:10 PM

Document Has Been Signed on 06/19/2024 05:17 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:LIBERTY HARMONYFACILITY NUMBER:
374604207
ADMINISTRATOR/
DIRECTOR:		MANIPON, CHERIFERFACILITY TYPE:
737
ADDRESS:2915 DUCK POND LANETELEPHONE:
(760) 975-7176
CITY:RAMONASTATE: CAZIP CODE:
92065
CAPACITY: 4CENSUS: 4DATE:
06/19/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:45 PM
MET WITH:Cherifer Manipon, Program DirectorTIME VISIT/
INSPECTION COMPLETED:
05:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dawn Segura conducted an unannounced Case Management - Incident visit. LPA identified herself, was granted entry into the facility, and met with Cherifer Manipon, Program Director, to whom LPA disclosed the purpose of the visit.

Today's visit was initiated in response to an SOC341 Report of Suspected Dependent Adult/Elder Abuse, which was received on 5/31/2024, in which licensee self-reported that Staff 1 (S1) [LIC 811 Confidential Names List was provided to identify the client and staff] pulled Client 1’s (C1) hair. Licensee promptly conducted an internal investigation, the results of which were quickly provided to Community Care Licensing. Interviews conducted and video surveillance revealed that, on the morning of 5/30/2024, C1 pulled S1’s hair, and S1 immediately responded by extending his/her arm and briefly pulling C1’s hair.

A Special Incident Report was also received on 6/5/2024, in which it was self-reported that, while unloading groceries from a vehicle, a staff who was serving as C1’s 1:1 staff, was summoned to assist with an incident occurring with another client. Upon returning to C1, Pine-Sol cleaner was left on a table in C1’s presence. While C1’s 1:1 staff was obtaining a snack for C1, C1 grabbed the bottle of Pine-Sol and placed it to his/her lips. C1’s 1:1 staff was able to obtain the bottle from C1 before C1 had an opportunity to ingest the liquid; however, C1 was able to place the cleaner to his/her lips. Poison control was contacted and medical advice/attention was sought. C1 was monitored for the remainder of the day and, reportedly, C1 did not exhibit adverse effects.

During today’s visit, LPA performed a brief facility tour and welfare check, observing clients who were present during the visit. No safety concerns were noted.

Based on evidence provided, deficiencies are being cited Per Title 22, Division 6, Chapter 8 of the California Code of Regulations in response to both of the above identified incidents and are listed on an LIC 809-D.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dawn Segura
LICENSING EVALUATOR SIGNATURE: DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2024
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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Document Has Been Signed on 06/19/2024 05:17 PM - It Cannot Be Edited


Created By: Dawn Segura On 06/19/2024 at 09:42 AM
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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: LIBERTY HARMONY
FACILITY NUMBER: 374604207

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/25/2024
Section Cited
CCR
80072(a)(1)

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Personal Rights. Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (1)To be accorded dignity in his/her personal relationships with staff and other persons.
This req't was not met, as evidenced by:
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S1 is no longer working in the facility. Program Director stated that staff are required to complete training relative to personal rights by 6/21/2024. Program Director offered to provide proof of training to Community Care Licensing by the POC due date of 6/25/2024.
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Based on interviews, the licensee did not ensure that 1 of 4 (C1) clients in care was accorded dignity in their personal relationship with S1. This posed a potential personal rights risk to a person in care.
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Type B
07/09/2024
Section Cited
CCR80087(g)

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Buildings and Grounds. Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.
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Program Director stated that staff are required to complete training relative to safeguarding clients and chemical safety by 7/5/2024. Program Director offered to provide proof of training to Community Care Licensing by the POC due date of 7/9/2024.
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Based on interviews, the licensee did not ensure that a disinfectant cleaning solution was stored where inaccessible to 1 of 4 (C1) clients in care. This posed a potential health risk to a person 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:Lizzette Tellez
LICENSING EVALUATOR NAME:Dawn Segura
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2024


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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: LIBERTY HARMONY
FACILITY NUMBER: 374604207
VISIT DATE: 06/19/2024
NARRATIVE
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An exit interview was conducted, and this report was discussed with Cherifer Manipon. Copies of the report and Licensee/Appeal Rights (LIC 9058 3/22) were provided to the Program Director, whose signature below acknowledges receipt of the rights and a copy of this report.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dawn Segura
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
LIC809 (FAS) - (06/04)
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