<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426281
Report Date: 08/16/2022
Date Signed: 08/16/2022 02:34:29 PM

Document Has Been Signed on 08/16/2022 02:34 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:TERRACE GARDENSFACILITY NUMBER:
366426281
ADMINISTRATOR:MAWIKERE, DEKKIFACILITY TYPE:
740
ADDRESS:22626 FLAMINGO ST.TELEPHONE:
(909) 824-8126
CITY:GRAND TERRACESTATE: CAZIP CODE:
92313
CAPACITY: 6CENSUS: 6DATE:
08/16/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Dekki Mawikere, AdministratorTIME COMPLETED:
02:37 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) Anna Bueno conducted an unannounced visit to the facility to initiate the complaint investigation and deliver findings for complaint number: 56-AS-20220808090401. LPA met with Dekki Mawikere, administrator, who was explained the purpose of today’s visit.

During the complaint investigation, LPA Bueno found that both side gates are secured but one of the gates is locked. LPA also found that Resident 1 (R1) was receiving nonprescription PRN medication. This poses a potential risk for residents in care. Refer to LIC-809D for deficiencies cited.

An exit interview was conducted where this report, LIC-809D, and appeal rights were discussed and provided to Mr. Mawikere.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
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 02:34 PM - It Cannot Be Edited


Created By: Anna Bueno On 08/16/2022 at 01:59 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: TERRACE GARDENS
FACILITY NUMBER: 366426281

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/31/2022
Section Cited
CCR
87705(l)(2)

1
2
3
4
5
6
7
The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates.
1
2
3
4
5
6
7
Licensee shall keep both side gates secured but not locked in any capacity. If Licensee wishes to keep gates locked, Licensee shall submit proof to the Department that requirements as outlined in CCR Section 87705(l) no later that end of POC date, 8/31/2022.
8
9
10
11
12
13
14
This requirement was not met as evidenced by:

LPA and Staff 1 viewed one of two side gates secured and locked with padlock. This poses a potential safety risk to residents in care.
8
9
10
11
12
13
14
Type B
08/31/2022
Section Cited
CCR87465(b)

1
2
3
4
5
6
7
If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted to assist the resident with self-administration of his/her PRN medication.
1
2
3
4
5
6
7
Licensee shall submit written proof of Resident's physician's order for two nonprescription PRN medication no later than the end of POC date, 8/31/2022.
8
9
10
11
12
13
14
This requirement was not met as evidenced by:
Administrator interview showed that Resident 1 is receiveing two nonprecription PRN medications. This poses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
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:Anna Bueno
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)
Page: 2 of 2