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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800424
Report Date: 03/05/2024
Date Signed: 03/05/2024 12:47:19 PM


Document Has Been Signed on 03/05/2024 12:47 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:EASTVALE SENIOR HOME CARE IIFACILITY NUMBER:
331800424
ADMINISTRATOR:BADILLA, ADELAIDAFACILITY TYPE:
740
ADDRESS:14318 PINTAIL LOOPTELEPHONE:
(951) 220-7354
CITY:EASTVALESTATE: CAZIP CODE:
92880
CAPACITY:6CENSUS: 4DATE:
03/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Rea Badillo Alim TIME COMPLETED:
12:50 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 caregiver Rosendo Lara and was granted entry to the facility. The facility is a (5) bedroom (2) bathroom home and, with a kitchen/dining area, living room, attach garage. LPA was accompanied by Administrator Rea Badillo Alim 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 residents in care. There was a designated space for client/staff files.

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.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary RicoTELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2024
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 3


Document Has Been Signed on 03/05/2024 12:47 PM - It Cannot Be Edited

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: EASTVALE SENIOR HOME CARE II
FACILITY NUMBER: 331800424

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(5)

87705 Care Of Person with Dementia
(5) Each Resident with dementia shall have an annual medical assesment as specified in Section 87458, Medical Assement, and a reppariasal done at least annual, both of which shall include a ressessment of the resident's dementia care needs.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above in by 1 out of the 4 dementia residents do not have their annual medical assesment which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/06/2024
Plan of Correction
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The licensee has agreed to send LPA the annual medical assesment.The licensee has agreed to read regulation 87705 entirely and send LPA a self-certified letter that the regulation was read and understood.
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 MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary RicoTELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


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: EASTVALE SENIOR HOME CARE II
FACILITY NUMBER: 331800424
VISIT DATE: 03/05/2024
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Record Review: Based on record review 1 out 2 dementia residents did not have an updated Physician Report. LPA also reviewed (2) staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings.

Based on the observations made during today’s visit, one (1) Type A 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 Administrator Rea Badillo Alim. Along with the appeal rights.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary RicoTELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024
LIC809 (FAS) - (06/04)
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