336403698-11-30-2021-19-CR-LYCS-C7HW2T-20211005165451

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336403698
Report Date: 10/05/2021
Date Signed: 11/30/2021 09:43:10 AM

Document Has Been Signed on 11/30/2021 09:43 AM - 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, 3737 MAIN ST., SUITE 600
RIVERSIDE, CA 92501

FACILITY NAME:	LYON		FACILITY NUMBER:	336403698
ADMINISTRATOR:	DAVID HARPER		FACILITY TYPE:	733
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 6		CENSUS: 5	DATE:	10/05/2021
TYPE OF VISIT:	Annual/Required	UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Residential Manager, Tyresha Calhoun		TIME COMPLETED:	05:00 PM

NARRATIVE

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***This is an Amended Report of the report issued on 10/05/21.

On October 5, 2021, at 11:20 AM Licensing Program Analyst (LPA) Leslie Covarrubias and Licensing Program Manager (LPM) Jennifer Smith arrived at Lyon, Short Term Residential Program (STRTP). LPA and LPM met with Residential Manager, Tyresha Calhoun. The purpose of the visit is to conduct an annual inspection of the facility. At 11:40 AM, Residential Manager, Tyresha Calhoun, led the physical inspection of the facility.

The home is set up as follows:

Bedroom #1- Was furnished with one twin bed. Sleeps one client. Bedroom #2- Was furnished with one twin bed. Sleeps one client. Bedroom #3- Was furnished with one twin bed. No client is placed in this room at this time. Bedroom #4- Was furnished with one twin bed. Sleeps one client. Bedroom #5- Was furnished with one twin bed. Sleeps one client. Bedroom #6- Was furnished with one twin bed. Sleeps one client.

Bedrooms are arranged so that only one child is placed per room. No room commonly used for other purposes is used as a bedroom, and no bedroom serves as a passageway to another room. There is adequate drawer and closet space for children’s belongings. The dresser drawer in room #2 was observed to be cracked approximately in the middle of drawer and on the verge of breaking off.

A physical plant inspection was completed and included the facility’s kitchen area, three refrigerators/freezers, food storage areas, client rooms, two bathroom/showers, and community gathering area and dining area. Facility grounds are clean and free of debris and observable hazards.

Sports equipment/toys/books/games were observed for client's recreation time. There is adequate indoor and outdoor activity space. Facility smoke detectors and carbon monoxide detectors are in appropriate working

SUPERVISORS NAME: Jennifer Smith
LICENSING EVALUATOR NAME: Leslie Y Covarrubias
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021

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 11/30/2021 09:45 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 11/29/2021 10:06 AM

Created By: Leslie Y Covarrubias On 10/05/2021 at 02:58 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
CCLD Regional Office, 3737 MAIN ST., SUITE 600
RIVERSIDE, CA 92501

FACILITY NAME: LYON	FACILITY NUMBER: 336403698
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/05/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Deficiency Dismissed

Type A

Section Cited

CCR

80074(c)

Transportation

(c) Motor vehicles used to transport clients shall be maintained in a safe operating condition. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	No deficiencies cited.
	POC Due Date: 10/11/2021
	Plan of Correction
1 2 3 4	No deficiencies cited.

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:

Jennifer Smith

LICENSING EVALUATOR NAME:

Leslie Y Covarrubias

LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021

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, 3737 MAIN ST., SUITE 600
RIVERSIDE, CA 92501

FACILITY NAME: LYON	FACILITY NUMBER: 336403698
	VISIT DATE: 10/05/2021

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order; fire extinguisher is properly charged and serviced. Licensee maintains an adequate supply of perishable and non-perishable foods and the menus were posted.

At the time of inspection the facility license was observed to be posted in the staff office, which is not a public area of the facility. All required forms are posted including the Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsperson poster. Medications are locked and centrally stored inside staff office. Individual beds were observed with appropriate clean linens, pillows, comforters, and mattresses in good repair. The hot water in the client’s bathrooms was measured to be an appropriate temperature. Per the Residential Manager, no firearms or weapons are allowed in the facility.

LPA and LPM inspected the facility vehicle, and observed that the second row seat belt buckles are missing the outside covers. The facility was advised not to allow use of the second row until repair of the seat belt buckles is completed. LPA and LPM also inspected the First Aid Kit and found it was missing tweezers and scissors.

Licensee has Mental Health Program Approval that is valid through 12/2021. Licensee has obtained National Accreditation that is valid through 10/2021. Licensing fee payments have been paid and there is currently a balance of $0.

No deficiencies were cited at this time. An exit interview was conducted and a copy of this report, LIC9102 and appeal rights were provided to Residential Manager, Tyresha Calhoun.

SUPERVISORS NAME: Jennifer Smith
LICENSING EVALUATOR NAME: Leslie Y Covarrubias
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021

LIC809 (FAS) - (06/04)

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