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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800124
Report Date: 09/05/2023
Date Signed: 09/05/2023 03:32:42 PM

Document Has Been Signed on 09/05/2023 03:32 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:NEW ERA 1 CARE HOMEFACILITY NUMBER:
331800124
ADMINISTRATOR:HERNANDEZ, FLORANTEFACILITY TYPE:
735
ADDRESS:2152 S VICENTIA AVENUETELEPHONE:
(310) 418-0718
CITY:CORONASTATE: CAZIP CODE:
92882
CAPACITY: 6CENSUS: 3DATE:
09/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:29 PM
MET WITH:Florante HernadezTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Rico made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Administrator Florante Hernandez and was granted entry to the facility. The facility is a (5) bedroom, (2) bathroom home and, with a kitchen/dining area, living room and attach garage. The facility is an Adult Residential Facility (ARF) level 2 designated home vendor by Inland Regional Center. Licensed capacity is (6) current census (3). LPA was accompanied by Facility staff Winnie Greco to conduct a general overall inspection, which included, but was not limited to, the following:

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. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean. LPA observed sufficient furniture and lighting throughout the facility. The hot water temperature tested within regulation at 116 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. All sharps are locked. There was a designated space for client/staff files. LPA observed stove nob missing and appliances were not operating. LPA observed outdoor furniture not comfortable for clients in care.

Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a variety of food available for clients. Dishes, cups, and utensils were also stored properly.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE: DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2023
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
Document Has Been Signed on 09/05/2023 03:32 PM - It Cannot Be Edited


Created By: Mary Rico On 09/05/2023 at 02:52 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: NEW ERA 1 CARE HOME
FACILITY NUMBER: 331800124

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPA obsevered one (1) person with out criminal clearance sleeping in the staff room the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/06/2023
Plan of Correction
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Licensee informed LPA that facility will provide documents of the staff schedule, criminal clearance, staff training of criminal clearance, and criminal clearance of new employee.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Efren Malagon
LICENSING EVALUATOR NAME:Mary Rico
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/05/2023 03:32 PM - It Cannot Be Edited


Created By: Mary Rico On 09/05/2023 at 02:52 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: NEW ERA 1 CARE HOME
FACILITY NUMBER: 331800124

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPA obesevred stove nob missing and not operating, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/12/2023
Plan of Correction
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Licensee informed LPA that the facility will fix the stove's nob and will send picture to LPA via email
Type B
Section Cited
CCR
85087.2(b)
Outdoor Activity Space
(b) The outdoor activity area shall provide a shaded area, and shall be comfortable, and furnished for outdoor use.

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPA obeserved outdoor patio funtuire not comfortable for clients, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/12/2023
Plan of Correction
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Licensee infromed LPA that the facility will provide a new outdoor furniture and will send picture to LPA via email
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:Efren Malagon
LICENSING EVALUATOR NAME:Mary Rico
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2023


LIC809 (FAS) - (06/04)
Page: 3 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: NEW ERA 1 CARE HOME
FACILITY NUMBER: 331800124
VISIT DATE: 09/05/2023
NARRATIVE
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Record Review: LPA reviewed two (2) client files for admission agreements, updated physician reports, and needs and services plans. LPA reviewed two (2) client medications and P&I were reviewed. LPA also reviewed two (2) staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings. LPA observed one person sleeping in the staff room with no criminal record clearance.

Based on the observations made during today’s visit, three (3) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809) and (LIC809D) was discussed and provided to Administrator Florante Hernandez, along with a copy of the appeal rights and LIC421BG.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2023
LIC809 (FAS) - (06/04)
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