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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004732
Report Date: 06/14/2024
Date Signed: 06/14/2024 11:05:11 AM

Document Has Been Signed on 06/14/2024 11:05 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ADELANTO COVENANT CARE, LLCFACILITY NUMBER:
306004732
ADMINISTRATOR/
DIRECTOR:		JOSEPH A. CARDELLAFACILITY TYPE:
740
ADDRESS:24901 ADELANTO DRIVETELEPHONE:
(310) 595-4482
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY: 6CENSUS: 4DATE:
06/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Joseph CardellaTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Administrator Joseph Cardella and explained the reason for the visit. Facility is a single story home with 7 bedrooms, 5 bathrooms, living room, activity room, dining room and kitchen. LPA observed the See Something, Say Something Poster (PUB 475) posted in the entry way of the facility. LPA observed the fireplace in the living room is screened. LPA and the Administrator toured the facility. LPA observed all resident rooms had the required furnishings. Extra linens and bedding are stored in the hall pantry. All resident bathrooms are clean and operational. Hot water measured 111.0 degrees Fahrenheit. No obstacles or hazards observed inside of the facility. The smoke detectors/carbon monoxide detectors tested operational. LPA inspected the kitchen. LPA observed the kitchen is clean and organized. LPA observed a two day perishable and a seven day non-perishable food supply on hand in the kitchen. The stove lights unassisted. LPA observed the fire extinguisher in the kitchen is fully charged. The knives and sharp objects are kept locked in a kitchen drawer. Cleaning supplies are kept locked under the kitchen sink. LPA toured the backyard. The exit gate is operational. No bodies of observed. LPA observed there is a shaded seating area for the residents to sit outside. LPA toured the garage. The garage is used for storage and off limits to the residents. LPA reviewed resident medications, no discrepancies observed. LPA reviewed 4 out of 4 resident records, no discrepancies observed. LPA reviewed 4 out of 4 staff files. LPA observed that Staff 1's and Staff 2's, 20 hours of annual training could not be verified. No other discrepancies observed. Deficiencies are being cited per Title 22 division 6 of the California Code of Regulations. An exit interview was conducted and a copy of the report provided along with appeal rights.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2024
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 06/14/2024 11:05 AM - It Cannot Be Edited


Created By: Joseph Alejandre On 06/14/2024 at 10:40 AM
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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ADELANTO COVENANT CARE, LLC
FACILITY NUMBER: 306004732

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 4 staff files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/01/2024
Plan of Correction
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Licensee agrees to ensure all staff are trained as required by the regulation and to document all training hours by staff. Licensee to forward proof to LPA that Staff 1 and Staff 2 have completed 20 hours of current annual training.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Sheila Santos
LICENSING EVALUATOR NAME:Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2024


LIC809 (FAS) - (06/04)
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