331800213-10-7-2023-56-AS-RNIS-CWDU4G-20231007151508

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331800213
Report Date: 10/07/2023
Date Signed: 10/07/2023 03:15:44 PM

Document Has Been Signed on 10/07/2023 03:15 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
, CA 92507

FACILITY NAME:	CALLA LILY RESIDENTIAL CARE		FACILITY NUMBER:	331800213
ADMINISTRATOR:	MORALES, DENIS		FACILITY TYPE:	735
ADDRESS:	4286 PONDHILL CT		TELEPHONE:	(951) 772-0003
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92505
CAPACITY:	4	CENSUS: 4	DATE:	10/07/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:50 AM
MET WITH:	Crystal Cortez, house manager		TIME COMPLETED:	03:25 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	Licensing Program Analyst (LPA) Rayshaun Nickolas visited the facility unannounced to complete a comprehensive annual inspection. LPA Nickolas met caregiver Oscar Beltran and explained the purpose of the visit, house manager Crystal Cortez would later arrive at the facility. Today’s inspection included a facility tour, record reviews, and interviews with one (1) staff and one (1) resident. The facility has five (5) bedrooms and three (3) bathrooms, of which four (4) bedrooms and two (2) bathrooms are used for residents in care. The facility also has a living room, family room, formal dining room, office, covered patio, and attached garage. Licensed capacity is four (4), and the census is at maximum capacity. Physical Plant: There are no obstructions to indoor and outdoor passageways. The facility temperature is 77 degrees Fahrenheit upstairs and 76 degrees Fahrenheit downstairs. LPA inspected resident bedrooms; each room included required furniture such as mattresses, nightstands, storage space, chair, and sufficient lighting; bathrooms were clean, and appliances were functional. LPA Nickolas' observed adequate furniture and lighting throughout the facility. The hot water temperature tested within regulation at 105.6-113.6 degreesFahrenheit. The facility has operating smoke and carbon monoxide detectors, which LPA Nickolas tested during the visit. The facility has three (3) charged fire extinguishers that is serviced by Fire Master. LPA Nickolas observed that cleaning supplies, toxins, sharps, and other dangerous items are kept secure and inaccessible to residents in care. There was a designated storage space for client/staff files. LPA Nickolas observed medications locked and inaccessible to residents in care. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care. Food Service: Non-perishable and perishable food supply is sufficient in number for residents in care. The facility has a variety of food available for clients. Dishes, cups, and utensils were also appropriately stored.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Rayshaun Nickolas	TELEPHONE: 951-255-9516
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2023

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 18

Document Has Been Signed on 10/07/2023 03:15 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
, CA 92507

FACILITY NAME: CALLA LILY RESIDENTIAL CARE	FACILITY NUMBER: 331800213
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

80087 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the perimeter fencing is leaning in the backyard, and LPA Nickolas' was unable to open the fence gate because it was loose, which poses a potential health, safety, and personal rights violation to persons in care.
	POC Due Date: 11/07/2023
	Plan of Correction
1 2 3 4	Licensee shall repair the perimeter fence. Proof of this correction shal lbe submitted to the Regional Office (RO) by the POC due date of 11/07/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Rayshaun Nickolas	TELEPHONE: 951-255-9516
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2023

LIC809 (FAS) - (06/04)

Page: 17 of 18

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
, CA 92507

FACILITY NAME: CALLA LILY RESIDENTIAL CARE	FACILITY NUMBER: 331800213
	VISIT DATE: 10/07/2023

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
26
27
28
29
30
31
32

Care & Supervision: The facility staff is sufficient in number for the care and supervision of residents in care. All staff members working in the facility have criminal record clearance through the department.

Record Review: LPA Nickolas reviewed four (4) resident files for admission agreements, updated physician reports, and needs and services plans. LPA Nickolas audited all four (4) residents' Medications and appeared to be dispensed appropriately by staff members. LPA Nickolas reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings.

During today’s inspection, LPA Nickolas observed that the perimeter fencing was leaning in the backyard. LPA Nickolas could also not open the perimeter fence side gate because the fence was loose. LPA Nickolas’ also issued 15 technical violations (LIC 9102 TV) during today’s inspection.

Based on observations made during today’s inspection, one (1) deficiency was cited per Title 22, Division 6, of the California Code of Regulations (CCR).

An exit interview was conducted and a copy of this report, LIC 809D, and Appeal Rights, LIC 9102 TV, were given to the Cortez.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Rayshaun Nickolas	TELEPHONE: 951-255-9516
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2023

LIC809 (FAS) - (06/04)

Page: 18 of 18