331880531-12-21-2023-56-AS-MBRN-CYR23C-20231221160207

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880531
Report Date: 12/21/2023
Date Signed: 12/21/2023 04:02:23 PM

Document Has Been Signed on 12/21/2023 04:02 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:	AVERY GARDEN ASSISTED LIVING INC.		FACILITY NUMBER:	331880531
ADMINISTRATOR:	THOMAS, LINDA		FACILITY TYPE:	740
ADDRESS:	5377 FULMER COURT		TELEPHONE:	(951) 934-3140
CITY:	JURUPA VALLEY	STATE: CA	ZIP CODE:	91752
CAPACITY:	6	CENSUS: 5	DATE:	12/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Licensee/Administrator Linda Thomas		TIME COMPLETED:	04:05 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 12/21/2023 at 09:00 AM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Brown met with a staff, was granted entry to the facility. At the time of the visit there were three (3) staff present, and five (5) residents present. Licensee/Administrator Linda Thomas was contacted and arrived during the visit. The facility is a five (5) bedroom, three (3) and half bathroom home with a kitchen/dining area, living room and attached two (2) car garage. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) residents of which (6) can be non-ambulatory residents and six (6) may be bedridden resident. The facility has six (6) Hospice Waiver. The current census is five (5) residents. LPA Brown was accompanied by Licensee/Administrator Linda Thomas (S1) 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). LPA Brown observed no obstructions to outdoor passageways. The facility is maintained at a comfortable temperature. LPA Brown inspected resident 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 Brown observed grab bars and non-skid mat or strips in the resident bathrooms. There was a designated storage space for resident/staff files. The facility has a locked medication room where residents medications are stored. Also, LPA Brown observed a complete first aid kit maintained and readily available at the facility and first aid books. To add to that, LPA Brown measured and observed the water temperatures in the bathroom to be at 112 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, infection control plan, Labor Laws and the disaster plan were posted in a common area. *Continuation in LIC809C *

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: AVERY GARDEN ASSISTED LIVING INC.	FACILITY NUMBER: 331880531
	VISIT DATE: 12/21/2023

NARRATIVE

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Food Service: Seven (7) days of non-perishable and three (3) days perishable food supply observed at the facility.

Care & Supervision: The facility has an administrator present in the facility and Staff #2 (S2) as a designee. LPA Brown observed sufficient number of staff to provide care and supervision to the residents in care.

Record Review: LPA reviewed five (5) resident files for admission agreements, updated physician reports, pre-admission appraisals, reappraisals and needs and services plans. LPA Brown observed complete physician’s reports, admissions agreements, needs and services plan, pre-admission appraisal however, LPA Brown observed no yearly reappraisal completed for Resident #2 (R2) as required. Deficiency will be issued. LPA Brown reviewed six (6) staff files for First Aid and CPR certification, criminal record clearance, trainings, and health screenings and Tuberculosis (TB) Test result. LPA Brown observed that Staff #2 (S2), Staff #3 (S3), Staff #4 (S4) and Staff #8 (S8) do not have their First Aid Certification their file. Deficiency will be issued. Also, LPA Brown observed Staff #7 (S7) without TB test result/information in S7 file. Moreover, LPA Brown observed Staff #8 (S8) and Staff #7 (S7) did not complete the required six (6) hours of dementia training as required by subdivision (a) of Section 1569.696 before working independently with residents. In addition, LPA Brown observed Staff #2 (S2), Staff #4 (S4) and Staff #7 (S7) and Staff #8 (S8) did not complete the required additional eight (8) hours of dementia training as required by subdivision (a) of Section 1569.626. Deficiencies will be issued. Also, LPA Brown observed Resident #2 (R2) with half bed rail and no record/documentation or written order from R2's physician indicating the need for half bed rail for R2's mobility. Deficiency will be issued. Licensee/Administrator Linda Thomas removed the half bed rail during the visit. LPA Brown also observed no record of earthquake drill completed at the facility. Deficiencies will be issued.

Furthermore, LPA Brown observed Staff #3 (S3) working at the facility without criminal background clearance transfer. Deficiency and civil penalty of $500.00 will be issued during the facility visit today and will continue to be assessed of $100.00 per day until corrected. Licensee/Administrator Thomas transferred S3 criminal background to the facility during the visit. Medications/Medication Administration Records (MAR) records were audited and appeared to be dispensed appropriately by staff members.

An exit interview was conducted where this report (LIC809), LIC809D, LIC421BG and Appeal Rights were discussed and provided to Licensee/Administrator Linda Thomas

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: AVERY GARDEN ASSISTED LIVING INC.	FACILITY NUMBER: 331880531
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)(11)

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: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not having a completed Health Screening Report for Staff #7 (S7) as S7 does not have TB Test Result/Information on S7 file which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/08/2024
	Plan of Correction
1 2 3 4	The Licensee stated to submit a copy of S7's completed Health Screening Report to LPA Brown at Plan of Correction (POC) due date.

Type B

Section Cited

CCR

87355(e)(3)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not transferring Staff #3 (S3) criminal record clearance to the facility which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/08/2024
	Plan of Correction
1 2 3 4	The Licensee transferred S3 criminal background clearance to the facility during the visit. POC cleared. The Licensee will submit Signed Statement of Understanding on CCR 87355(e)(3) to LPA Brown at POC due date.

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	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/21/2023 04:02 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: AVERY GARDEN ASSISTED LIVING INC.	FACILITY NUMBER: 331880531
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(c)(1)

Personnel Requirements - General

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not having Staff #2 (S2), Staff #3 (S3), Staff #4 (S4) and Staff #8 (S8) complete their First Aid Certification and maintain it in their file which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/08/2024
	Plan of Correction
1 2 3 4	The Licensee stated to submit S2, S3, S4 and S8 proof of completed First Aid Certification to LPA Brown at Plan of Correction (POC) due date.

Type B

Section Cited

HSC

1569.626(a)(1)

Other Provisions

(a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff: (1) Twelve hours of dementia care training, six of which shall be completed before a staff member begins working independently with residents, and the remaining six hours of which shall be completed within the first four weeks of employment. All 12 hours shall be devoted to the care of persons with dementia. The facility may utilize various methods of instruction, including, but not limited to, preceptorship, mentoring, and other forms of observation and demonstration. The orientation time shall be exclusive of any administrative instruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not having Staff #8 (S8) and Staff #7 (S7) complete the required six (6) hours of dementia training as required by subdivision (a) of Section 1569.696 before working independently with residents which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/08/2024
	Plan of Correction
1 2 3 4	The Licensee stated to submit proof of S8, S7 completed six (6) hours of dementia training to LPA Brown at POC due date.

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	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/21/2023 04:02 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: AVERY GARDEN ASSISTED LIVING INC.	FACILITY NUMBER: 331880531
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.626(a)(2)

Other Provisions

(a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff: (2) Eight hours of in-service training per year on the subject of serving residents with dementia. This training shall be developed in consultation with individuals or organizations with specific expertise in dementia care or by an outside source with expertise in dementia care. In formulating and providing this training, reference may be made to written materials and literature on dementia and the care and treatment of persons with dementia. This training requirement may be satisfied in one day or over a period of time. This training requirement may be provided at the facility or offsite and may include a combination of observation and practical application. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above by not having Staff #2 (S2), Staff #4 (S4), Staff #7 (S7) and Staff #8 (S8) complete the required additional eight (8) hours of dementia training as required by subdivision (a) of Section 1569.626 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/08/2024
	Plan of Correction
1 2 3 4	The Licensee stated to submit proof of S2, S4, S7 and S8 completed eight (8) hours of dementia training to LPA Brown at POC due date.

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	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/21/2023 04:02 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: AVERY GARDEN ASSISTED LIVING INC.	FACILITY NUMBER: 331880531
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not conducting the required earthquake drill on all shifts at the facility which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/08/2024
	Plan of Correction
1 2 3 4	The Licensee stated to submit proof of completed Earthquake drill on all shifts at the facility to LPA Brown at Plan of Correction due date.

Type B

Section Cited

CCR

87608(a)(5)(A)

Postural Supports

(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not having a record/documentation or written order from R2's physician indicating the need for half bed rail for R2's mobility. which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/08/2024
	Plan of Correction
1 2 3 4	The Licensee removed R2's half bedrail during the visit. POC cleared.

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	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/21/2023 04:02 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: AVERY GARDEN ASSISTED LIVING INC.	FACILITY NUMBER: 331880531
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(c)(6)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not completing the required yearly reappraisal for Resident #2 (R2) at the facility which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/08/2024
	Plan of Correction
1 2 3 4	The Licensee stated to complete the required yearly reappraisal for Resident #2 (R2) and submit copy of completed R2 reappraisal to LPA Brown at Plan of Correction (POC) due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

LIC809 (FAS) - (06/04)

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