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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601553
Report Date: 09/05/2023
Date Signed: 09/05/2023 03:19:21 PM

Document Has Been Signed on 09/05/2023 03:19 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CALIFORNIA MENTOR - MEADCLIFF HOMEFACILITY NUMBER:
198601553
ADMINISTRATOR:CHRIS SCHLANSERFACILITY TYPE:
734
ADDRESS:23612 MEADCLIFF PLACETELEPHONE:
(909) 274-7620
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY: 5CENSUS: 5DATE:
09/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Staff#1 TIME COMPLETED:
03:25 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 09/05/2023 at 8:26 am. LPA was met by Staff #1 (S1) and explained the purpose of the visit. This facility is licensed as an Adult Residential Facility for Persons with Special Healthcare Needs (ARFPSHN) and is vendored by San Gabriel/Pomona Regional Center. The facility is licensed to serve five (5) developmentally disabled clients ages 18 and above; of which five (5) may be bedridden. During today’s visit, LPA Ramirez observed four (4) staff members providing direct care and supervision to clients in care. LPA Ramirez requested and obtained copies of Personnel Report, and Client Roster.

LPA OBSERVATIONS: Tour began at 9:07 am and was led by LPA Ramirez. The facility is a single-story home that contains five (5) bedrooms fully equipped with mechanical lifts, two (2) bathrooms of which one (1) is equipped with a mechanical lift, living room, TV room, kitchen, dining room, laundry room, backyard shaded patio area, and attached garage. LPA Ramirez observed one (1) Registered Nurse (RN), two (2) Licensed Vocational Nurses (LVN), and one (1) Direct Support Personnel (DSP) during visit. Fully charged fire extinguishers were observed throughout the facility.

Front Yard: Was clean and well maintained. No hazards were observed. Passageways are free of any obstructions.

SEE 809-C for continuation.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2023
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CALIFORNIA MENTOR - MEADCLIFF HOME
FACILITY NUMBER: 198601553
VISIT DATE: 09/05/2023
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Kitchen: LPA Ramirez observed appliances to be clean and in working order. LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed knives and sharps located kitchen cabinet, to be inaccessible to five (5) out of five (5) clients in care. LPA Ramirez observed several bottles of cleaning solutions and disinfectants located in bottom kitchen cabinet to be inaccessible to five (5) out of five (5) clients in care. Signs promoting hand washing were observed in this area. Meal plan was observed in this area for two (2) clients in care.

Dining Room/Living room: Dining room was observed to be clean and contained one table with plenty of seating. Living room was observed plenty of seating and lighting.

Linen Closet: Contained plenty linens, towels, and hygiene products.

Client Rooms 1 - 5: LPA Ramirez observed all resident bedrooms to contain the required linens, furnishings, and lighting. LPA Ramirez observed mechanical lifts in all client bedrooms and were observed to be in working order. LPA Ramirez observed caution signs indicating “oxygen in use” near entry of client rooms where oxygen was in use.

Bathrooms: Water temperature in bathroom#1 was measured at 116.6 degrees F. Bathroom #2 water temperature was measured at 117.7 degrees F. Mechanical lift in bathroom# 2 was operable and tested during visit. LPA Ramirez observed a shower gurney in bathroom #2. LPA Ramirez observed five (5) individually labeled cabinets on nearby wall that contained individual hygiene products for each of the five (5) clients in care. All client bathrooms were observed to be clean and signs promoting hand washing were observed.

Laundry Area: LPA Ramirez observed laundry soap and supplies to inaccessible to five (5) out of five (5) clients in care. : LPA Ramirez observed oxygen tanks to be secured on stands. LPA Ramirez observed defibrilator and first aid kit in this area.

Centrally Stored Medications: LPA Ramirez medications cart to be locked and inaccessible to five (5) out of five (5) clients in care.

Backyard: No large bodies of water were observed. Passageways are free of any obstructions.

SEE 809-C for continuation.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2023
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CALIFORNIA MENTOR - MEADCLIFF HOME
FACILITY NUMBER: 198601553
VISIT DATE: 09/05/2023
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Attached Garage: Generator was observed and tested during visit. LPA Ramirez observed emergency water, food and disaster supplies in garage.

Emergency Drills: Proof of last documented earthquake drill was conducted 8/21/23 during AM shift.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide and smoke detectors in hallways. Smoke detectors were observed to be operable during visit.

Staff Personnel Files: Five (5) staff files were reviewed, and LPA Ramirez observed various in-house service trainings for the months of January 2023 through August 2023. Administrators Certificate for James C Schlanser with an expiration date of 09/06/23 was observed. Administrator Schlanser presented LPA Ramirez with proof of intent to renew administrator’s certificate.

Client Files: Five (5) client files were reviewed.

No deficiencies were cited. Exit interview conducted with Administrator Schlanser. A copy of this report was provided.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2023
LIC809 (FAS) - (06/04)
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