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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426418
Report Date: 04/05/2023
Date Signed: 04/05/2023 12:37:57 PM

Document Has Been Signed on 04/05/2023 12:37 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:M&M BOARD & CAREFACILITY NUMBER:
366426418
ADMINISTRATOR:MERCADO, VICTORFACILITY TYPE:
740
ADDRESS:18245 CHERRY ST.TELEPHONE:
(760) 488-1698
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY: 8CENSUS: 3DATE:
04/05/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:27 PM
MET WITH:Victor Mercado, LicenseeTIME COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Rayshaun Nickolas conducted a case management deficiency visit. The case management visit is in response to a deficiency cited at the facility. LPA met with Licensee Victor Mercado and explained the purpose of the visit.

During a facility file review, LPA discovered that the facility had not reported any unusual incident or injury to Community Care Licensing Division (CCLD) since November 2020. LPA also observed a bedroom window covered with window film installation and card board. LPA interview with the Licensee revealed that the window is broken. The Licensee also stated that they are in the process of getting the window repaired. However, the Licensee was unable to prove that they are in the process of repairing the window.

Based on observations made during today, two (2) deficiencies was cited per Title 22, Division 6, of the California Code of Regulations (CCR), Sections 87211 Reporting Requirements and Section
87303 Maintenance and Operation (a).
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An exit interview was conducted and a copy of this report, LIC 809D, and Appeal Rights were provided.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE: DATE: 04/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/05/2023
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 04/05/2023 12:37 PM - It Cannot Be Edited


Created By: Rayshaun Nickolas On 04/05/2023 at 12:10 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: M&M BOARD & CARE
FACILITY NUMBER: 366426418

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/17/2023
Section Cited
CCR
87211

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87211 Reporting Requirements

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following...

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The licensee shall provide training in the section cited to all staff. Licensee shall submit a letter of understanding to the Regional Office (RO) with training records by the POC due date.
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This requirement was not met as evidenced by.

Based on file review, the licensee did not ensure to report any unusual incidents or injuries since November 2020, which poses a health, safety, personal rights violation to clients in care.
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Type B
05/05/2023
Section Cited
CCR87303(a)

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87303 Maintenance and Operation (a)

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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The Licensee shall repair the bedroom window by the POC due date. If the Licensee is unable to have the window repaired due to supply chain or repairman issues, the Licensee shall submit proof that the repair is in process by submitting a receipt to the RO by the POC due date.
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This requirement was not met as evidenced by:

Based on observation, the Licensee did not ensure to maintain the facility in good repair, which poses a health, safety, personal rights violation to clients 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:Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2023


LIC809 (FAS) - (06/04)
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