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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603665
Report Date: 05/26/2022
Date Signed: 05/26/2022 11:14:28 AM

Document Has Been Signed on 05/26/2022 11:14 AM - 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:DEVON PLACE HOME CAREFACILITY NUMBER:
374603665
ADMINISTRATOR:MARK LOOFACILITY TYPE:
740
ADDRESS:1814 DEVON PLACETELEPHONE:
(760) 941-1818
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY: 6CENSUS: 6DATE:
05/26/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Maria Zavala, CaregiverTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conduct a case management visit to address a deficiency observed during the investigation of complaint control number 18-AS-20220520153932.
The floor in the area of the dining area was observed to be peeling, bubbled, chipped away, and misshapen.


Therefore, based on the observations made during today’s visit, the following deficiency was cited per Title 22, Division 6 of the California Code of Regulations. See LIC 809D. An exit interview was conducted and this reported was provided along with Appeal Rights.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Tricia Danielson
LICENSING EVALUATOR SIGNATURE: DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2022
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 05/26/2022 11:14 AM - It Cannot Be Edited


Created By: Tricia Danielson On 05/26/2022 at 10:58 AM
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: DEVON PLACE HOME CARE
FACILITY NUMBER: 374603665

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/09/2022
Section Cited
CCR
87307(d)(2)

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Personal Accomodations and Services- (d) The following space and safety provisions shall apply to all facilities: (2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement was not met as evidenced by:
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The facility will repair or replace the floor in the dining area and submit proof to CCL by POC due date of 6/9/2022.
If additional time is required to complete this POC, please conduct LPA prior to POC due date.
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The Licensee did not ensure the facility flooring was in good repair. Based on LPA observations, the floor in the area of the dining area was observed to be peeling, bubbled, chipped away, and misshapen
This poses a potential health, safety, and personal rights risks 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:Deborah Mullen
LICENSING EVALUATOR NAME:Tricia Danielson
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2022


LIC809 (FAS) - (06/04)
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