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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880753
Report Date: 12/18/2023
Date Signed: 12/18/2023 02:54:16 PM


Document Has Been Signed on 12/18/2023 02:54 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:JHEHAN FAITH LLCFACILITY NUMBER:
331880753
ADMINISTRATOR:TAGUBA, JENNIFER BFACILITY TYPE:
740
ADDRESS:5256 SIERRA VISTA AVENUETELEPHONE:
(717) 330-9409
CITY:RIVERSIDESTATE: CAZIP CODE:
92505
CAPACITY:6CENSUS: 3DATE:
12/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Licensee/Administrator Heldo TagubaTIME COMPLETED:
03:00 PM
NARRATIVE
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On 12/18/2023 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 three (3) residents present. Licensee/Administrator Heldo Taguba was contacted and arrived during the visit.

The facility is a five (5) bedroom, two (2) bathroom home with a kitchen/dining area, living room and detached garage/stock room. 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 one (1) may be bedridden resident. The facility has six (6) Hospice Waiver. The current census is three (3) residents. LPA Brown was accompanied by Licensee/Administrator Taguba (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 customized tiles that functions as non-skid mat or strips in the resident bathrooms. Moreover, during the tour of the facility, LPA Brown observed the knives drawer not locked in the kitchen and accessible to residents in care. Deficiency will be issued as this pose immediate safety risks to residents in care. There was a designated storage space for resident/staff files. There is a cabinet with the resident’s medications locked in the kitchen. Also, LPA Brown observed a complete first aid kit maintained and readily available at the facility however, no current edition of First Aid

***Continuation in LIC809C ***

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 12/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2023
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 4


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: JHEHAN FAITH LLC
FACILITY NUMBER: 331880753
VISIT DATE: 12/18/2023
NARRATIVE
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Manual approved by the American Red Cross, the American Medical Association or a state or federal health agency observed at the facility. Deficiency will be issued. To add to that, LPA Brown measured and observed the water temperatures in the bathroom to be at 115 degrees F. 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, Infection Control Plan were posted in a common area.

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. LPA Brown observed sufficient number of staff to provide care and supervision to the residents in care.

Record Review: LPA reviewed three (3) resident files for admission agreements, updated physician reports, and needs and services plans. The files were complete with updated physician’s reports, admissions agreements, and preadmissions appraisals. LPA reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA found that Staff #2 (S2) does not have Health Screening Report in S2’s facility file. Deficiency will be issued. Furthermore, LPA Brown observed Staff #3 (S3) working at the facility without criminal background clearance. 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. Medications/MARs 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 Heldo Taguba.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 12/18/2023 02:54 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: JHEHAN FAITH LLC
FACILITY NUMBER: 331880753

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(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
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not locking the drawer where the knives were kept making it accessible to residents in care which poses an immediate health, safety or personal rights risk to residents in care.
POC Due Date: 12/19/2023
Plan of Correction
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The Licensee stated to train all staff on CCR 87309(a) and submit proof to LPA Brown at Plan of Correction (POC) due date.
Type A
Section Cited
CCR
87355(e)
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:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by allowing Staff #3 (S3) to work at the facility without criminal background clearance which poses an immediate health, safety or personal rights risk to residents in care.
POC Due Date: 12/19/2023
Plan of Correction
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Licensee removed Staff #3 (S3) at the facility during the visit. POC cleared.
The Licensee stated to submit Signed Statement of Undestanding on CCR 87355(e) 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 MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 12/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 12/18/2023 02:54 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: JHEHAN FAITH LLC
FACILITY NUMBER: 331880753

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2023

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
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Based on observation, interview and record review, the licensee did not comply with the section cited above not having a completed Health Screening Report for Staff #2 (S2) in S2 staff file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2024
Plan of Correction
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The LIcensee stated to submit a copy of S2 completed Health Screening Report to LPA Brown at Plan of Correction (POC) due date.
Type B
Section Cited
CCR
87465(8)(A)
87465 Incidental Medical and Dental Care. (8) If facility has no medical unit...(A) A current edition of a first aid manual approved by the American Red Cross, the American Medical Associaltion or a state or federal health agency.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not having a current edition of a first aid manual approved by the American Red Cross, American Medical Associaltion or a state or federal agency at the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/29/2023
Plan of Correction
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The Licensee stated to submit proof of current edition of a first aid manual approved by the American Red Cross, American Medical Association or a state or federal agency 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 MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 12/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4