<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880803
Report Date: 11/07/2024
Date Signed: 11/07/2024 02:46:06 PM

Document Has Been Signed on 11/07/2024 02:46 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:ENJOYCARE-POPLARFACILITY NUMBER:
331880803
ADMINISTRATOR/
DIRECTOR:		SUSAN FRIESFACILITY TYPE:
740
ADDRESS:11574 POPLAR STREETTELEPHONE:
(909) 796-1375
CITY:LOMA LINDASTATE: CAZIP CODE:
92354
CAPACITY: 6CENSUS: 5DATE:
11/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:37 PM
MET WITH:Administrator Joy Boling TIME VISIT/
INSPECTION COMPLETED:
02:55 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
Licensing Program Analysts (LPAs) Sarina Ramirez and Renese Howell-Small made an unannounced visit to the facility to conduct a required annual inspection. LPAs met with Administrator Joy Boling, and discussed the purpose of the visit.

The facility is a Residential Care Facility for the Elderly (RCFE) with a license capacity of (6), a current census of (5). LPAs conducted an overall inspection of the facility, which included, but was not limited to, the following:

Physical Plant/Environment: Indoor and outdoor passageways are free of obstruction. The facility has no swimming pool or similar bodies of water. The facility has sufficient lighting and is maintained at a comfortable temperature. The facility has sufficient indoor and outdoor space for resident activities The facility is equipped with operating smoke detectors/carbon monoxide alarms, laundry equipment, and telephone service. Resident’s showers, toilets, and hand washing areas were operating properly. The hot water temperature in residents bathrooms measured between 107,109 and 110 degrees F. Five (5) resident’s bedrooms had beds, bed linen, chairs, dresser, storage space and sufficient lighting. The facility has sufficient linens, towels, and personal hygiene items for residents. Bedrooms and bathrooms do not have trash cans with tight fitting covers, deficiency will be cited. The facility has posted in a common area, facility license, personal rights, CCLD complaint poster, facility sketch, emergency telephone numbers, emergency disaster plan, activity schedule, resident roster, and menu.

Food Service: Facility kitchen and dining areas are maintained clean. The facility has sufficient non-perishable and perishable food supply for residents in care, however a non-perishable canned food was observed expired in the pantry. Deficiency will be cited. Sharps and chemicals were kept locked and inaccessible to residents in care.

Continuation on LIC – 809C:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2024
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 4
Document Has Been Signed on 11/07/2024 02:46 PM - It Cannot Be Edited


Created By: Sarina Ramirez On 11/07/2024 at 02:19 PM
Link to Parent Document Below:
The Facility Number was changed to 361880803 After this Document was created!
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: ENJOYCARE-POPLAR
FACILITY NUMBER: 331880803

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(9)
General Food Service Requirements
(b) The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation the licensee did not comply with the section cited above by ensuring all expired canned goods are disgarded which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/08/2024
Plan of Correction
1
2
3
4
Licensee agreed to train staff, created a log, and submit proof to LPA by POC due date
Type A
Section Cited
CCR
87465(c)(1)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (1) There is written direction from a physician, on a prescription blank, specifying the name of the resident, the name of the medication, all of the information specified in Section 87465(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication of when the physician should be contacted for a medication reevaluation.

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 documenting when the medication was given, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/08/2024
Plan of Correction
1
2
3
4
Licensee agreed to train staff on medication distribution and documentation, Licesee will submit proof to LPA by 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:Karen Clemons
LICENSING EVALUATOR NAME:Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 11/07/2024 02:46 PM - It Cannot Be Edited


Created By: Sarina Ramirez On 11/07/2024 at 02:19 PM
Link to Parent Document Below:
The Facility Number was changed to 361880803 After this Document was created!
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: ENJOYCARE-POPLAR
FACILITY NUMBER: 331880803

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(f)(3)
Maintenance and Operation
(f) Solid waste shall be stored and disposed of as follows: (3) All containers, except movable bins, used for storage of solid wastes shall have tight-fitting covers on the containers; shall be in good repair; shall have external handles; and shall be leakproof and rodent-proof.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by not having trash cans with tight fitting lids which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/16/2024
Plan of Correction
1
2
3
4
Licensee agreed to submit proof of new trash cans to LPA by 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:Karen Clemons
LICENSING EVALUATOR NAME:Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
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: ENJOYCARE-POPLAR
FACILITY NUMBER: 331880803
VISIT DATE: 11/07/2024
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
26
27
28
29
30
31
32
Care & Supervision: Facility has 24-hour/7days a week care staff. Facility staff have current CPR/first aid training.

Medical Related Services: Resident’s medications are labeled and centrally stored in a locked cabinet; LPAs found inconsistencies with medication distribution. Deficiency will be issued.

Record Review: Three (3) Staff files reviewed were observed to be complete. Five (5) Resident files reviewed were observed to be complete. Last disaster drill was conducted on 9/05/24.

Based on observations and record review deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report along with appeal rights were discussed and provided to Administrator Joy Boling.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4