365530141-10-9-2024-56-AS-MECA-D9VRUW-20241009132036

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 365530141
Report Date: 10/09/2024
Date Signed: 10/09/2024 01:20:47 PM

Document Has Been Signed on 10/09/2024 01:20 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	DESERT HORIZON RESIDENTIAL CARE II		FACILITY NUMBER:	365530141
ADMINISTRATOR/ DIRECTOR:	SHATTLES-BREEDLOVE, ANGELA		FACILITY TYPE:	740
ADDRESS:	13001 WALNUT WAY		TELEPHONE:	(760) 953-5286
CITY:	VICTORVILLE	STATE: CA	ZIP CODE:	92392
CAPACITY: 6		CENSUS: 6	DATE:	10/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:58 AM
MET WITH:	Bria Sheriff- Staff		TIME VISIT/ INSPECTION COMPLETED:	01:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with Staff, Bria Sheriff and introduced self and stated purpose of the visit. LPA was informed that there are currently 5 residents in care who are in the facility. The facility has (5) resident bedrooms, (3) resident bathrooms, living room, dining area, kitchen, pantry, laundry room, backyard, attached garage and side casita with bedroom and bathroom for staff. LPA completed a walk through of facility, review of records and medication audit. Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 77 degrees fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected resident bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 112.3 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, fire extinguisher and first aid kit. Posters such as; the personal rights, ombudsman and emergency disaster plans were posted in a common area. LPA observed a knife left in sink, 2 scissors in kitchen drawers, medication delivered on 9/18 inside the desk drawer, stool softener on top of desk, razors inside hallway cabinet, and detergent in cabinets all made accessible. Deficiency issued. There was a designated storage space for resident/staff files. Medications were observed secured and inaccessible to residents. There are no guns, ammunition, swimming pool or bodies of water in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care. Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Facility has a wide variety of food available for residents. Dishes, cups, and utensils were also stored properly.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024

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 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: DESERT HORIZON RESIDENTIAL CARE II	FACILITY NUMBER: 365530141
	VISIT DATE: 10/09/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Yards/Outside: One shaded patio, a side gate with self-latching handle on the left and right side of the house that leads into the backyard, and a casita with a bedroom and bath for staff. All outdoor pathways were free of obstructions.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department.

Record Review: LPA reviewed resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. Medications were audited at random and appeared to be dispensed appropriately by staff. The facility last conducted a drill on 7/14/24 .

One deficiency and one technical violation were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102TV and appeal rights were discussed and copies were provided to the Licensee, Angela Breedlove who arrived later.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 10/09/2024 01:20 PM - It Cannot Be Edited

Created By: Michelle Echeverria On 10/09/2024 at 12:44 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: DESERT HORIZON RESIDENTIAL CARE II	FACILITY NUMBER: 365530141
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by making the following accessible: a knife left in sink, 2 scissors in kitchen drawers, medication delivered on 9/18 inside the desk drawer, stool softener on top of desk, razors inside hallway cabinet, and detergent in cabinets which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/09/2024
	Plan of Correction
1 2 3 4	Licensee made all of the items that were found accessible inaccessibe during inspection. Licensee stated that she will conduct a refresh training with all staff and submit proof to LPA via email by 10/18/24.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Nedra Brown

LICENSING EVALUATOR NAME:

Michelle Echeverria

LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4