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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800124
Report Date: 08/30/2024
Date Signed: 08/30/2024 03:28:50 PM

Document Has Been Signed on 08/30/2024 03:28 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/
DIRECTOR:		HERNANDEZ, FLORANTEFACILITY TYPE:
735
ADDRESS:2152 S VICENTIA AVENUETELEPHONE:
(310) 418-0718
CITY:CORONASTATE: CAZIP CODE:
92882
CAPACITY: 6CENSUS: 3DATE:
08/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:05 PM
MET WITH:Elizabeth ChamenTIME VISIT/
INSPECTION COMPLETED:
03:40 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Mary Rico, Raquel Hernandez, and Eldin Serrano made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA 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 staff Elizabeth Chamen 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, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. 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. The hot water temperature tested within regulation at 106 degrees. There was a designated space for client/staff files.

During facility tour, LPA observed client’s dinning table dirty. Tablecloth observed to have food/liquid stains. In addition, the facility did not have their emergency disaster supplies ready and the activities calendar was not updated for the month July 2024. The last activity calendar that was created was March 2024.

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: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2024
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 6
Document Has Been Signed on 08/30/2024 03:28 PM - It Cannot Be Edited


Created By: Mary Rico On 08/30/2024 at 02:28 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: 08/30/2024

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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Based on observation the tablecloth was dirty, 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: 09/13/2024
Plan of Correction
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Based on observation the resident's tablecloth was dirty, had food/liquid stains 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.
Type B
Section Cited
CCR
85079(c)
Activities
(c) The licensee shall ensure that clients are given the opportunity to attend and participate in community activities including but not limited to the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the facility did not have an updated activity calendar. The last activity calendar was provided in March 2024, 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: 09/13/2024
Plan of Correction
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Administrator stated ensure an activity calendar will be created and will be provided to LPA.
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: 08/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2024


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 08/30/2024 03:28 PM - It Cannot Be Edited


Created By: Mary Rico On 08/30/2024 at 02:28 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: 08/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, S1 did not have a health screening, 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: 09/13/2024
Plan of Correction
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Administrator stated they will request for S1 to receive a health screening and will send a copy to LPA.
Type B
Section Cited
CCR
80069(b)(1)
Client Medical Assessments
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment. (1) Such assessment shall be performed by a licensed physician, or designee, who is also a licensed professional, and the assessment shall not be more than one year old when obtained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, 1 out of the 3 clients did not have an updated medical assessment 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: 09/13/2024
Plan of Correction
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The Administrator stated they will be obtaining a copy and send proof to LPA.
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: 08/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 08/30/2024 03:28 PM - It Cannot Be Edited


Created By: Mary Rico On 08/30/2024 at 02:28 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: 08/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(e)
Other Provisions
(e) A facility shall have all of the following information readily available during an emergency:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the resident's tablecloth was dirty, had food/liquid stains 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: 09/06/2024
Plan of Correction
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The Administrator stated the will have the following items readily available during an emergency and will send proof to LPA
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: 08/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 08/30/2024 03:28 PM - It Cannot Be Edited


Created By: Mary Rico On 08/30/2024 at 02:54 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: 08/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(6)(B)

(b) Clients shall be assisted as needed with self-administration of prescription and nonpresciption medications.(6) If the client is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the clients with self-administration,
provided all of the following requirement are met: (B) The date and time of each contact with the physician, and the physician's directions, shall be documented and maintained in the client's facility record
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, C1 medication from August 26 through 30, 2024 was not documented but was provided the licensee did not comply with the section cited above in which poses an immediate health, safety, or personal rights risk to persons in care.
POC Due Date: 09/03/2024
Plan of Correction
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Administrator stated they will train their staff on the regulation cited above and will send LPA proof.
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: 08/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2024


LIC809 (FAS) - (06/04)
Page: 5 of 6
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: 08/30/2024
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Record Review: LPA reviewed three (3) client files for admission agreements, updated physician reports, and needs and services plans. During record review, 1 out of the 3 clients did not have an updated physician report. LPA reviewed three (3) client medications. During medication audit, LPA observed C1 medication from August 26 through 30, 2024 was not documented but was provided, S2 admitted they forgot to document C1 medication on the MAR, LPA also reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA observed S1 did not have a completed health screening.

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

An exit interview was conducted, and this report (LIC809)(LIC809D) was discussed and provided to staff Elizabeth Ratliff. Along with the appeals right.

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

DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2024
LIC809 (FAS) - (06/04)
Page: 6 of 6