366423467-6-14-2023-56-AS-ACON-CSSTY3-20230614150803

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366423467
Report Date: 06/14/2023
Date Signed: 06/14/2023 03:08:11 PM

Document Has Been Signed on 06/14/2023 03:08 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:	NEW DISCOVERY RESIDENTIAL SERVICES #5		FACILITY NUMBER:	366423467
ADMINISTRATOR:	DONNA WELDON		FACILITY TYPE:	735
ADDRESS:	33974 AVENUE "H"		TELEPHONE:	(909) 918-0059
CITY:	YUCAIPA	STATE: CA	ZIP CODE:	92399
CAPACITY:	4	CENSUS: 3	DATE:	06/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:48 PM
MET WITH:	Amanda Link, Staff Member		TIME COMPLETED:	03:15 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 Analyst, Amber Coleman, (LPA) arrived at the New Discovery Residential Services #5 Adult Residential Facility unannounced to conduct an Annual Inspection. LPA was greeted by staff member, Amanda Link and granted entry inside facility. LPA signed in was provided a space to work. Staff Member, Amanda Link reported there were 3 residents in care. 2 residents were present during LPA's visit. The Administrator was contact to notify of LPA visit; who later arrived during LPA visit. LPA's visit included a walk through of the facility, staff and resident interviews and review of staff and resident files. The facility is a residential home with 4 bedrooms, 2 bathrooms, 2 Living Rooms, Dining Room, Kitchen, Backyard and attached garage. The facility is a level 4 designated home vendorized by Inland Regional Center. LPA conducted a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected resident bedrooms; they each included required furniture such as: mattresses, bedding, night stands, storage space, and sufficient lighting. At approximately, 1:25pm LPA observed that a resident room near the main entrance of the facility was missing a window screen. LPA inspected resident bathrooms; bathrooms were observed to be clean and in good repair. LPA observed adequate paper and hand hygiene supplies. LPA tested the temperature from the bathroom faucet, which ranged between 114-112 F. The facility is equipped with operational smoke detectors and carbon monoxide alarms. The facility conduct fire and earthquake drills twice a month. Last drill was conducted on 6/1/23. Please see LIC9099-C

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023

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: NEW DISCOVERY RESIDENTIAL SERVICES #5	FACILITY NUMBER: 366423467
	VISIT DATE: 06/14/2023

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LPA observed posters for resident personal rights, disaster/evacuation plans and infection control were posted throughout the. Cleaning supplies, toxins, sharps, and other dangerous items are kept inaccessible to residents. LPA observed the items in secure cabinets and drawers throughout the facility. There was a designated storage space for client/staff files in the Living Room. Medications were locked and inaccessible to residents. The facility had emergency and first aid kits readily available for residents in care.

Food Service: Non-perishable and perishable food supply is sufficient for number of clients residing in the facility. Facility has a variety of food available for residents as evidenced by the weekly posted food menu. Dishes, cups, and utensils were also stored properly. Emergency food and water were also observed.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department.
Record Review: LPA reviewed 2 resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed 2 staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. P & I funds were counted at random and matched with the ledger. Medications were audited at random and appeared to be dispensed appropriately by staff members.

Based on observations, no deficiencies will be cited per Title 22, California Code of Regulations. A copy of this report was read/reviewed with Licensee; signature acknowledges understanding and receipt of report and attachments.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023

LIC809 (FAS) - (06/04)

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