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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800086
Report Date: 11/29/2021
Date Signed: 11/29/2021 05:19:30 PM

Document Has Been Signed on 11/29/2021 05:19 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:CALIFORNIA HOME FOR THE ADULT DEAF (CHAD)FACILITY NUMBER:
331800086
ADMINISTRATOR:DANNY BARRETTFACILITY TYPE:
740
ADDRESS:3615 CROWELL AVETELEPHONE:
(626) 701-8960
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY: 6CENSUS: 6DATE:
11/29/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Danny Barrett - AdministratorTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of continuing investigation of a complaint (#18-AS-20200316140401). While at the facility, LPA Colvin observed the following items that were not in compliance with Title 22 Regulations:
  • Licensing Fees - During LPA Colvin's preparation for today's inspection, LPA Colvin observed that the Licensee is behind on their annual fees, and has not made a payment towards their fees since 1/31/20. As of today's inspection, the Licensee owes California Department of Social Services (CDSS) $1,236.50. This is a combination of annual licensing fees and late penalties, which have been accruing since 2019. Deficiency cited.

  • Obstructed Walkway - Upon LPA Colvin's arrival, LPA Colvin observed that the walkway leading from the driveway to the front door of the facility was partially blocked by a pile of dirt and a traffic/hazard cone. This obstruction covered more than 50% of the width of the walkway. The facility is licensed for non-ambulatory residents, which further implores the need for clear walkways at all times. Deficiency cited.

  • Reporting Requirements - During LPA Colvin's investigation today, LPA Colvin observed records from an Emergency Room for one resident (R1) from March 2021 in relation to a fall. LPA Colvin's review of the facility's submitted incident reports shows that no reports were submitted since 2019. Administrator Danny was able to produce reports for this incident and others, though it does not appear that they were sent to Licensing.

Based on LPA Colvin's observations, the facility was cited. LPA Colvin provided a copy of this report, LIC809Ds, and appeal rights to Administrator Danny Barrett.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 11/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2021
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 11/29/2021 05:19 PM - It Cannot Be Edited


Created By: Crystal Colvin On 11/29/2021 at 02:08 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: CALIFORNIA HOME FOR THE ADULT DEAF (CHAD)
FACILITY NUMBER: 331800086

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/13/2021
Section Cited
HSC
1569.185(e)

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Fees for license or applications; use of revenues; collected; denial or forfeiture: (e) The failure of an applicant for licensure or a licensee to pay all applicable and accrued fees and civil penalties shall constitute grounds for denial or forfeiture of a license. This requirement was not met as evidenced by:
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Licensee agrees to pay all fees due by Plan of Correction date of 12/13/21. Licensee may self-certify to LPA Colvin once payment has been made.
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Based on record review, the Licensee did not comply with the above regulation with the facility's licensing fees. LPA Colvin observed that the Licensee owes $1,236.50 and has been behind on licensing fees since 2019. This is a potential safety risk for all residents, as the license may be revoked.
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Type B
12/13/2021
Section Cited
CCR87307(d)(6)

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Personal Accommodations and Services: (d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement was not met as evidenced by:
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Licensee agrees to remove debris from walkway by Plan of Correction date of 12/13/21. Licensee to provide LPA Colvin with photographic proof of cleared walkway.
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Based on observations, the Licensee did not comply with the above requirement with at least one walkway. LPA Colvin observed the walkway from the driveway to the front door to be over halfway obstructed by a pile of dirt and a hazard cone. This is a potential safety risk to all residents in care.
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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:Joel Esquivel
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/29/2021 05:19 PM - It Cannot Be Edited


Created By: Crystal Colvin On 11/29/2021 at 02:54 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: CALIFORNIA HOME FOR THE ADULT DEAF (CHAD)
FACILITY NUMBER: 331800086

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/30/2021
Section Cited
CCR
87211(a)(1)(D)

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Reporting Requirements: (a) Each licensee shall furnish...such reports...including...the following: (1) A written report shall be submitted...within seven days of...any of the events specified...(D) Any incident which threatens the welfare, safety or health of any resident... This requirement was not met by:
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Licensee agrees to review Title 22 Regulation Section 87211 regarding Reporting Requirements, as well as conduct an all-staff training on Reporting Requirements. Licensee may self-certify completion of review of Regulation Section 87211, and to submit Statement of Understanding regarding
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Based on record review, the Licensee did not comply with the above regulation with at least one resident. LPA Colvin observed that R1 went to the Emergency Room in March 2021 in regards to a fall, but no report was submitted to Licensing. This is an immediate personal rights violation of R1.
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requirements for reporting incidents to Licensing. Self-certification and Statement of Understanding to be submitted to LPA Colvin by Plan of Correction date of 11/30/21.

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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:Joel Esquivel
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2021


LIC809 (FAS) - (06/04)
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