Community Care Licensing

SUPERVISOR'S NAME: Nedra Brown TELEPHONE: (951) 202-5776 LICENSING EVALUATOR NAME: Bianca Wolcott TELEPHONE: (951) 248-0306 LICENSING EVALUATOR SIGNATURE: DATE: 01/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/04/2024

Document Has Been Signed on 01/04/2024 05:53 PM - It Cannot Be Edited

FACILITY NAME: MIRA LOMA SENIOR CARE	FACILITY NUMBER: 331880632
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/04/2024

Type A

Section Cited

CCR

87309(a)

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. 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 in by not securing the cleaning solutions & chemicals and not making it accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/05/2024
	Plan of Correction
1 2 3 4	Licensee agreed to remove all cleaning solutions and chemicals and store in locked laundry room or new lock needs to be installed on hallway closet door and submit proof to LPAs at plan of correction due date.

Type A

Section Cited

CCR

87465(a)(6)

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. 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 updating resident #2 and resident #1 medication adminstrator records when dispensing R2 & R1 medications which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/05/2024
	Plan of Correction
1 2 3 4	Licensee stated to train all staff on CCR 87465(a)(6) and submit proof of Training log to LPAs at POC due date.

SUPERVISOR'S NAME: Nedra Brown TELEPHONE: (951) 202-5776 LICENSING EVALUATOR NAME: Bianca Wolcott TELEPHONE: (951) 248-0306 LICENSING EVALUATOR SIGNATURE: DATE: 01/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/04/2024

Document Has Been Signed on 01/04/2024 05:53 PM - It Cannot Be Edited

FACILITY NAME: MIRA LOMA SENIOR CARE	FACILITY NUMBER: 331880632
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/04/2024

Type A

Section Cited

CCR

87705(f)(1)

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). 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 locking the knives & lighters making it accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/05/2024
	Plan of Correction
1 2 3 4	Licensee removed knife from broken cabinet and put in the unlocked cabinet that stored the knives & lighter. Licensee was made aware broken cabinet needs to be repaired, and knives& lighter need to be locked in a cabinet and not accessible to residents in care.

Section Cited

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

SUPERVISOR'S NAME: Nedra Brown TELEPHONE: (951) 202-5776 LICENSING EVALUATOR NAME: Bianca Wolcott TELEPHONE: (951) 248-0306 LICENSING EVALUATOR SIGNATURE: DATE: 01/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/04/2024

Document Has Been Signed on 01/04/2024 05:53 PM - It Cannot Be Edited

FACILITY NAME: MIRA LOMA SENIOR CARE	FACILITY NUMBER: 331880632
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/04/2024

Type B

Section Cited

CCR

87468(c)(1)

(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (1) The personal rights of residents specified in Sections 87468.1, Personal Rights of Residents in All Facilities and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities shall be posted as applicable to the facility. 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 in by not having the personal rights available in the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/19/2024
	Plan of Correction
1 2 3 4	Licensee is aware personal rights need to be accessible for each client at facility.

Type B

Section Cited

CCR

87465(a)(8)(A)

(8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following: (A) A current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency. 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 in by not having current addition of a first aid manuel approved by the American Red Cross, American Medical Association or State or Federal Agency. Which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/19/2024
	Plan of Correction
1 2 3 4	Licensee stated to submit proof of First Aid Manual, approved by American Red Cross and submit proof to LPAs by POC due date.

SUPERVISOR'S NAME: Nedra Brown TELEPHONE: (951) 202-5776 LICENSING EVALUATOR NAME: Bianca Wolcott TELEPHONE: (951) 248-0306 LICENSING EVALUATOR SIGNATURE: DATE: 01/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/04/2024

Document Has Been Signed on 01/04/2024 05:53 PM - It Cannot Be Edited

FACILITY NAME: MIRA LOMA SENIOR CARE	FACILITY NUMBER: 331880632
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/04/2024

Type B

Section Cited

HSC

1569.695(e)(2)

(e) A facility shall have all of the following information readily available to facility staff during an emergency: (2) An appraisal of resident needs and services plan for each resident. 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 the required needs and services plan for resident #1 & #2 at the facility which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/19/2024
	Plan of Correction
1 2 3 4	Licensee stated to complete the required needs and services plan for resident #1 & #2 and submit to LPAs at POC due date.

Type B

Section Cited

CCR

87608(a)(5)(A)

(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, record review, the licensee did not comply with the section cited above in by not having a doctors written order on the half bed rail for resident #2 & resident #3 indicating half bed rail for mobility which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/19/2024
	Plan of Correction
1 2 3 4	Licensee stated to submit the doctors written order indicating resident #2 & resident #3 half bed rail for mobility to LPAs on POC due date.

SUPERVISOR'S NAME: Nedra Brown TELEPHONE: (951) 202-5776 LICENSING EVALUATOR NAME: Bianca Wolcott TELEPHONE: (951) 248-0306 LICENSING EVALUATOR SIGNATURE: DATE: 01/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/04/2024

FACILITY NAME: MIRA LOMA SENIOR CARE	FACILITY NUMBER: 331880632
	VISIT DATE: 01/04/2024

NARRATIVE

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Dental- LPA reviewed resident records. Two (2) residents files & (3) staff files were reviewed. LPA reviewed for admission agreement, medical assessment, consent forms, identification and emergency information, appraisal needs and service plans, centrally stored medication/destruction records,safeguard for personal property/valuables, and personal rights notification. Food Service- LPAs were present during the lunch time meal. The meal is adequate to meet the nutritional needs of the residents. Food prep areas are clean and organized. Food supply meets the requirement of one week supply of nonperishable and 2-day supply of perishables food on hand. LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. The facility has not exceeded its capacity limitation and the structure remains unchanged according to the approved floor plan. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguishers are tested or replaced annually, last done on 03/2/23. The facility is conducting emergency disaster drills last one done 9/21/23. Fire drills were conducted on 8/20/23. This report was reviewed with and a copy provided to the facility representative. .