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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336427235
Report Date: 08/16/2022
Date Signed: 08/16/2022 03:07:46 PM

Document Has Been Signed on 08/16/2022 03:07 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
, CA 92507
FACILITY NAME:CORONA RESIDENTIAL CARE CENTER LLCFACILITY NUMBER:
336427235
ADMINISTRATOR:AHARON STRIKSFACILITY TYPE:
740
ADDRESS:1400 CIRCLE CITY DRTELEPHONE:
(951) 735-0252
CITY:CORONASTATE: CAZIP CODE:
92879
CAPACITY: 125CENSUS: 97DATE:
08/16/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Maria Gonzales AdministratorTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bernadette Allen and Melody Brown conducted an unannounced visit to this facility investigate complaint control # 56-AS-20220809145821. LPA met with Maria Gonzales

LPA observed the following deficiency while investigating complaint control #56-AS-20220809145821.



During the tour of the facility LPA's observed the shower room was not locked which had cleaning supplies sitting on the floor between the sink and cabinet. There were other cleaning supplies under the sink in a unlocked cabinet, accessible to clients in care. LPA'S Allen and Brown will be issuing a deficiency for this issue as this poses immediate health and safety risk to residents in care.

An exit interview was conducted where this report, LIC809, LIC809-D, and Appeal Rights were discussed and provided to administrator Maria Gonzales.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 08/16/2022 03:07 PM - It Cannot Be Edited


Created By: Bernadette Allen On 08/16/2022 at 02:26 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
, CA 92507

FACILITY NAME: CORONA RESIDENTIAL CARE CENTER LLC
FACILITY NUMBER: 336427235

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/17/2022
Section Cited
CCR
80087(g)

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80087-Buildings and Grounds (g)(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirement is not met as evidence by:
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Licesseed stated will train all staff on CCR 80087(g) and submit training log to LPA Allen by 8/17/2022 POC date. Licensee will submit a written statement of understanding on CCR 80087(g) to LPA by POC date.
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Based on interviews and record review the licensee did not comply with the section cited above by not having the cleaning supplies locked and unaccessable to residents in care which poses immediate health,safty 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:Karen Clemons
LICENSING EVALUATOR NAME:Bernadette Allen
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2022


LIC809 (FAS) - (06/04)
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