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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800086
Report Date: 07/01/2022
Date Signed: 07/01/2022 01:05:04 PM

Document Has Been Signed on 07/01/2022 01:05 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:
07/01/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:26 AM
MET WITH:Marisa Andrade, CaregiverTIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA), Jesse Gardner, conducted an unannounced visit in reference to the facility being previously identified to be over capacity. LPA met with Caregiver, and informed her of the purpose of her visit.

LPA then toured the facility, and found 6 residents in care. Thus the facility was deemed to be in compliance with the capacity.

Upon the tour of the facility, LPA learned of Resident R1 passing away recently. It was proposed that through interview with Licensee Danny Barrett via phone, that resident R1's daughter took resident to the hospital on 5/25/2022 and R1 passed away.

LPA reviewed Department records, and found that the facility did not report the death to CCL, and thus a deficiency was cited.

An exit interview was conducted where a copy of this report was discussed with a provided to Ms. Andrade.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 07/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2022
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 07/01/2022 01:05 PM - It Cannot Be Edited


Created By: Jesse Gardner On 07/01/2022 at 11:23 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
, 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: 07/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/15/2022
Section Cited
CCR
87211(a)(1)(A)

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REPORTING REQUIREMENTS: (a) Each licensee shall furnish to the licensing..reports..(1)..report shall be submitted..This requirement was not being met as evidenced by:
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Licensee states that a death report will be submitted by POC date. Licensee to further submit a memorandum of understanding via email to LPA by POC date.
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Based on LPA's review of Department records revealed that the Licensee did not submit a death report for R1. This poses a potential health and safety risk to residents in care.
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Type B
07/15/2022
Section Cited
CCR87506(d)

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RESIDENT RECORDS: (d)..All resident records shall be available to the licensing..This requirement was not being met as evidenced by:
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Licensee states that records will be provided to Licensing staff in the future, and will provide a memorandum of understanding to LPA via email by POC date.
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Based on LPA's review, staff could not provide resident records for R1, thus the Licensee did not comply with regulation. This poses a potential health and safety and personal rights risk to 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:Deborah Mullen
LICENSING EVALUATOR NAME:Jesse Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2022


LIC809 (FAS) - (06/04)
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