331880731-10-4-2024-56-AS-ESEO-D9QTQQ-20241004145618

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880731
Report Date: 10/04/2024
Date Signed: 10/04/2024 02:56:27 PM

Document Has Been Signed on 10/04/2024 02:56 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	MCT HOME		FACILITY NUMBER:	331880731
ADMINISTRATOR/ DIRECTOR:	STIEN BAWENGAN		FACILITY TYPE:	735
ADDRESS:	31376 TULETTE LN		TELEPHONE:	(714) 414-2246
CITY:	WINCHESTER	STATE: CA	ZIP CODE:	92596
CAPACITY: 4		CENSUS: 4	DATE:	10/04/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:30 PM
MET WITH:	Rinny Tapan, Caregiver		TIME VISIT/ INSPECTION COMPLETED:	03:15 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 10/04/2024 at 12:30 PM, Licensing Program Analysts (LPAs) Melody Brown and Eldin Serrano conducted an unannounced visit to the facility to conduct the required comprehensive annual inspection to the facility. LPAs Brown and Serrano were greeted by Caregiver Rinny Tapan and gained access at the home. LPAs Brown and Serrano explained the purpose of the visit to Administrator Stein Bawengan . The facility has five (5) bedrooms, three (3) bathrooms, kitchen, dining room, living room, attached garage, and backyard. The facility is vendorized by Inland Regional Center (IRC). The facility are licensed for 4 and 3 of which can be non-ambulatory. LPAs Brown and Serrano completed a walkthrough of the facility, review of records, Personal and Incidental (P&I) and medications audit. Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD), LPAs Brown and Serrano observed one (1) client during the visit. There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 73 degrees Fahrenheit. LPAs Brown and Serrano inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, chairs, and sufficient lighting. LPAs Brown and Serrano inspected client bathrooms; bathrooms were clean, and appliances were found functional. Water temperatures tested at 115 degrees Fahrenheit. The facility is equipped with operational smoke detectors and carbon monoxide detectors, charged fire extinguisher, and first aid kit with first aid book. In addition, LPAs Brown and Serrano observed non-slip mat on client’s bathroom. Posters such as the personal rights, CCLD complaint poster, and emergency disaster plan were posted in a common area. Client medications were kept in secure cabinets inaccessible to clients. LPAs Brown and Serrano observed night lights at the hallway leading to clients' shared bathrooms. The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility. * Continuation in LIC809C *

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2024

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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MCT HOME	FACILITY NUMBER: 331880731
	VISIT DATE: 10/04/2024

NARRATIVE

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Yards/Outside: One shaded patio, one (1) side gate with self-latching handle on the left side of the house that leads into the backyard, attached two (2) car garage observed. All outdoor pathways were free of obstructions.

Food Service: LPAs Brown and Serrano observed two (2) day(s) supply of perishable food and seven (7) day(s) supply of non-perishables food and snacks. Dishes, cups, and utensils were stored properly.

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

Record Review: LPAs Brown and Serrano reviewed three (3) client files for admission agreements, medical assessments/physician reports, and Individual Program Plan (IPP) and centrally stored medications list. LPAs Brown and Serrano observed files reviewed were complete. LPAs Brown and Serrano also reviewed staff and administrator's file for First Aid/CPR and emergency intervention certification (CPI), criminal record clearance, trainings, and health screenings with tuberculosis (TB) test result.

Also, LPAs Serrano and Brown observed Client #4 (C4) with full bed rails and Administrator Bawengan reported to LPAs Serrano and Brown that C4 is not on Hospice Care and per documents review, no exception letter submitted and approved by Community Care Licensing Division (CCLD) for C4's full bed rails. Deficiency will be issued.

LPAs Brown and Serrano audited three (3) clients’ medications and no issues were observed. LPAs Brown and Serrano audited three (3) client's Personal and Incidental (P&I) and no issues observed.

Deficiency was cited during this visit. An exit interview was conducted where this report LIC809, LIC809D, and Appeal Rights were discussed, and copies were provided to Administrator Stein Bawengan.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/04/2024 02:56 PM - It Cannot Be Edited

Created By: Eldin Serrano On 10/04/2024 at 02:36 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: MCT HOME	FACILITY NUMBER: 331880731
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80072(a)(8)(E)1

Personal Rights

1. A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. Bed rails that extend the entire length of the bed are prohibited except for clients who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. 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 allowing client #4 (C4) to have full bedrail and C4 is not on hospice and does not have an exception letter approve by CCLD for the full bedrail which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/05/2024
	Plan of Correction
1 2 3 4	Licensee removed C4 full bedrail during the visit. Plan of correction cleared.

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:

Karen Clemons

LICENSING EVALUATOR NAME:

Eldin Serrano

LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2024

LIC809 (FAS) - (06/04)

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