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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366410678
Report Date: 10/15/2021
Date Signed: 10/15/2021 01:41:17 PM

Document Has Been Signed on 10/15/2021 01:41 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:CANYON HILLS CARE HOMEFACILITY NUMBER:
366410678
ADMINISTRATOR:MELJORIE CASTELOFACILITY TYPE:
740
ADDRESS:7791 STEWART ROADTELEPHONE:
(909) 433-0612
CITY:COLTONSTATE: CAZIP CODE:
92324
CAPACITY: 6CENSUS: 6DATE:
10/15/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Shirley Digma - CaregiverTIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of conducting a follow-up visit regarding complaint (#18-AS-20210126093050). LPA Colvin met with Caregiver Shirley DIgma and advised them of the purpose of the visit. During LPA Colvin's visit, LPA Colvin addressed the following issue which was discovered during the investigation:

Through LPA Colvin's investigation of the complaint (#18-AS-20210126093050), LPA Colvin observed that one resident (R1) had been admitted to the hospital at least twice in 2020 (11/5/20 for 8 days and 12/5/20 for 7 days). Community Care Licensing (CCL) never received an Incident Report from the facility regarding these hospitalizations. In fact, CCL did not receive any Incident Reports or Death Reports from the facility for a period of over two years (8/7/18 to 1/5/21). All unusual incidents which may pose a risk to a resident's health or safety (such as: calls to 911 or medical emergencies) are to be reported to CCL within 7 calendar days. Deficiency cited.

LPA Colvin conducted an exit interview with Caregiver Shirley Digma, and a copy of this report, LIC809D, and appeal rights were provided.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2021
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 10/15/2021 01:41 PM - It Cannot Be Edited


Created By: Crystal Colvin On 10/14/2021 at 04:31 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: CANYON HILLS CARE HOME
FACILITY NUMBER: 366410678

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/18/2021
Section Cited
CCR
87211(a)(1)(D)

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Reporting Requirements: (a) Each licensee shall furnish to the licensing agency...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 was not met by:
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Licensee agrees to review Title 22 Regulation Section 87211 regarding Reporting Requirements as well as have staff re-trained on reporting requirements. Licensee to submit proof of training as well as Statement of Understanding to LPA Colvin regarding reporting incidents to CCL by Plan of Correction
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Based on record review, the Licensee did not comply with the above regulation with at least two incidents. LPA Colvin observed that R1 was hospitalized for a week twice in 2020 (11/5/20 & 12/10/20) but the facility never submitted an Incident Report to CCL. This was an immediate personal rights risk to R1.
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date of 10/18/21.

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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: 10/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2021


LIC809 (FAS) - (06/04)
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