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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336413251
Report Date: 05/24/2023
Date Signed: 05/31/2023 09:03:15 AM

Document Has Been Signed on 05/31/2023 09:03 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:HAPPY NEST IIFACILITY NUMBER:
336413251
ADMINISTRATOR:CLAIRE ITCHONFACILITY TYPE:
740
ADDRESS:3180 E. VISTA CHINOTELEPHONE:
(760) 992-9645
CITY:PALM SPRINGSSTATE: CAZIP CODE:
92262
CAPACITY: 6CENSUS: 6DATE:
05/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Claire Itchon, AdministratorTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction, visit purpose and provided the facility caregiver with LPA identification.

Resident record review began. Two (2) records were reviewed. LPA reviewed for admission agreement, medical assessment and TB test results, consent forms, identification and emergency information, appraisal needs and service plans/Individual Program Plans, centrally stored medication/destruction records, safeguard for personal property/valuables-missing for R1, and personal rights notification. This facility is meeting documentation requirements. Two (2) residents were interviewed.

LPA began review of employee records. Two (2) records were reviewed. LPA reviewed employee record for first aid certification, fingerprint clearance, personnel/job application, health screening and TB test results, criminal record statement, employee rights, training verification, and current administrator certification. CPR and requirements have been met. The facility employs enough staff to maintain cleanliness and meet the needs of the clients in care. Administrator certification is present and current. Two (2) staff were interviewed.


Due to time constraints, Inspection will need to be concluded at another day.


Based on the information received during this visit today, one (1) deficiency is being cited per Title 22, Division 6 of The California Code of Regulations.

This report, 809D and Appeal rights was reviewed with and a copy will be emailed and a confirmation of receipt will be requested.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2023
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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Document Has Been Signed on 05/31/2023 09:03 AM - It Cannot Be Edited


Created By: Yolanda Delgado On 05/24/2023 at 03:42 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: HAPPY NEST II
FACILITY NUMBER: 336413251

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(5)
INCIDENTAL MEDICAL AND DENTAL CARE SERVICES: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Delgado's observation interview and record review, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed meds in cups and medication trays for future dispensing.
POC Due Date: 05/31/2023
Plan of Correction
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Licensee will educate staff, constant monitoring and update pharmacy on packaging, inform family, resident and provider and will submit In-Service training via email to LPA by POC due date.
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:Jazmond D Harris
LICENSING EVALUATOR NAME:Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2023


LIC809 (FAS) - (06/04)
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