336403613-10-24-2023-56-AS-ACON-CWWUDK-20231024152941

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336403613
Report Date: 10/24/2023
Date Signed: 10/24/2023 03:30:19 PM

Document Has Been Signed on 10/24/2023 03:30 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	JIREH HOUSE		FACILITY NUMBER:	336403613
ADMINISTRATOR:	CASSANDRA KNIGHTEN		FACILITY TYPE:	735
ADDRESS:	51935 RIZA		TELEPHONE:	(951) 849-1985
CITY:	CABAZON	STATE: CA	ZIP CODE:	92230
CAPACITY: 5		CENSUS: 1	DATE:	10/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Cherron Jackson, Administrator.		TIME COMPLETED:	03:30 PM

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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Jireh House, Adult Residential Facility unannounced to conduct the Annual Inspection. LPA rang the doorbell, then was greeted by Administrator, Cherron Jackson, who granted LPA entry. LPA introduced self and stated purpose of the visit. LPA signed in and was provided was to work. LPA was informed 1 resident home at the time of the visit.

The facility is comprised of 3 bedrooms, 2 bathrooms, kitchen, dining room, den, living room, backyard and attached garage. The facility is vendorized by the Inland Region Center at level 4I. Licensed capacity is (5) and current census of 3. The facility is operating in the capacity approved by Community Care Licensing (CCL). LPA was accompanied by Administrator on a walk through of the facility for a general overall inspection, which included, but was not limited to, the following:

Physical Plant: Interior and Exterior pathways were unobstructed and free of clutter. The facility is maintained at a comfortable temperature. LPA inspected resident rooms which all included all required furniture such as: mattresses, linens, sufficient lighting and storage space. Each bathroom was orderly and included adequate hand hygiene materials with operational appliances.

Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a variety of food available for clients. Dishes, cups, and utensils were also stored properly.

LPA observed sufficient furniture in good repair and sufficient lighting throughout the facility. The hot water temperature tested within regulatory limits. The facility is equipped with operational smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents. There was a designated storage space for residents/staff files. Medications are kept inside medication closet inaccessible to resident. Overall, the facility is neat, orderly and in good repair, and operating in safe conditions for resident in care.

Please see LIC809-C

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

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

FACILITY NAME: JIREH HOUSE	FACILITY NUMBER: 336403613
	VISIT DATE: 10/24/2023

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LPA reviewed resident records for Physician's Reports, Needs and Services, IPP's and Admissions Agreements. LPA observed that 2 resident records included out of Physician's Reports (LIC602). Staff records were reviewed for training, CPR/First Aid, criminal record/fingerprints clearance and found that staff records included all documents as regulated.

Based on observations, a deficiency will be cited per Title 22, California Code of Regulations to address resident records. A copy of this report was read/reviewed with Licensee; signature acknowledges understanding and receipt of report and attachments.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/24/2023 03:30 PM - It Cannot Be Edited

Created By: Amber Coleman On 10/24/2023 at 03:16 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: JIREH HOUSE	FACILITY NUMBER: 336403613
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80069(c)

Client Medical Assessments

(c) The medical assessment shall include the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations and record reviews the licensee did not comply with the section cited above by not ensuring the resident files included up to date Physician's Reports for 2 residents. Which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/24/2023
	Plan of Correction
1 2 3 4	Administrator agrees to have the resident's Physician's Reports completed by the resident's Primary Physician and submit verification to the Community Care Licensing Office within 30 business days.

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:

Nedra Brown

LICENSING EVALUATOR NAME:

Amber Coleman

LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

LIC809 (FAS) - (06/04)

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