336400036-4-26-2023-18-AS-JSRS-CR9RNZ-20230426131111

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336400036
Report Date: 04/26/2023
Date Signed: 04/26/2023 01:11:15 PM

Document Has Been Signed on 04/26/2023 01:11 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	GIL'S BOARD AND CARE II		FACILITY NUMBER:	336400036
ADMINISTRATOR:	GIL, ELIZABETH		FACILITY TYPE:	735
ADDRESS:	2168 STONEFIELD PLACE		TELEPHONE:	(951) 787-8771
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92506
CAPACITY: 6		CENSUS: 4	DATE:	04/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:58 AM
MET WITH:	Facility Manager-Javier Gil		TIME COMPLETED:	01:15 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 Manager, (LPM) Jazmond Harris and Licensing Program Analyst (LPA), Jacqueline Shaw Ross conducted an unannounced visit to the facility for the purpose of a required annual inspection. LPA and LPM met with Facility Manager, Javier Gil and explained the nature of the visit and was granted entry into the facility. The facility was inspected inside and out. At the time of the visit, two staff and one client was present. The home is one story and has four bedrooms and three bathrooms. The facility appears clean and free of odors. Staff present have criminal record clearances and are appropriately associated to the facility. Client bedrooms are clean and appropriately furnished. All smoke and carbon monoxide detectors were tested and found operational. Food supplies are sufficient. Emergency food and water was stored in the garage. Hot water was measured in the client's bathroom and deemed safe. LPA observed all toxic chemicals and other hazards secured and inaccessible to clients. Medications are centrally stored in the staff office. Furniture in the home is in good repair. Outdoor space is free of hazards. LPM and LPA inspected the staff and client records. After review, it was observed that client files do not have needs and service plans. LPA advised Facility Manager that the client files should maintain needs and service and updated Individual Person Plans per Title 22 Regulations. Technical Assistance was provided to remind the facility to ensure that all client placement agreements are signed and dated. After review of the Administrator file, it was observed that the Administrator Certificates was expired. Administrator stated that the required documentation was sent for the certifications to be updated. A Technical Advisory was provided to the facility.Staff files had the required documentation including First Aid Certifications and training documents. P&I monies are kept in the client folders and are maintained separately from facility funds. LPA inspected medications and medications appear to be dispensed appropriately according to the physician's orders. The facility is completing emergency drills monthly. Staff and client interviews were conducted. An exit interview was conducted and a copy of the report, LIC 9099D, and technical advisory and violation was provided.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023

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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Document Has Been Signed on 04/26/2023 01:11 PM - It Cannot Be Edited

Created By: Jacqueline Shaw Ross On 04/26/2023 at 12:37 PM

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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GIL'S BOARD AND CARE II	FACILITY NUMBER: 336400036
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85068.3(a)

Modifications to Needs and Services Plan

(a) The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental and/or social functioning. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in four out of four residents, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/10/2023
	Plan of Correction
1 2 3 4	Facility Manager indicates that the client's case managers will be contacted in order to obtain updated and accurate needs and service plans for all clients in care. Needs and service plans will be sent to LPA in order to review.

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:

Jazmond D Harris

LICENSING EVALUATOR NAME:

Jacqueline Shaw Ross

LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023

LIC809 (FAS) - (06/04)

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