331881043-3-14-2024-56-AS-RGAR-D3CRPT-20240314131228

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881043
Report Date: 03/14/2024
Date Signed: 03/14/2024 01:12:34 PM

Document Has Been Signed on 03/14/2024 01:12 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	NOAH'S ARK ADULT HOME		FACILITY NUMBER:	331881043
ADMINISTRATOR:	ANGUIANO, RUTH		FACILITY TYPE:	735
ADDRESS:	20094 KLYNE ST.		TELEPHONE:	(951) 707-6803
CITY:	CORONA	STATE: CA	ZIP CODE:	92881
CAPACITY: 4		CENSUS: 2	DATE:	03/14/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Ruth Anguiano- Administrator		TIME COMPLETED:	01:20 PM

NARRATIVE

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Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Administrator Ruth Anguiano and was granted entry to the facility.

The facility is an Adult Residential Facility (ARF) licensed for a capacity of four (4) ambulatory clients, two (2) residents may be non-ambulatory. The facility is level 4g vendorized by Inland Regional Center (IRC). The current census is two (2) clients. LPA was accompanied by Administrator to conduct a general overall inspection, which included, but was not limited to, the following:

The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to interior and exterior passageways. The facility is maintained at a comfortable temperature. LPA inspected client 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 observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperature in the bathrooms to be at 105 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. The postings such as the facility license, personal rights, the CCL complaint poster, labor laws, and the disaster plan were posted in a common area. The cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. There was a designated storage space for the client files and the staff files. The medications are kept inside a locked cabinet in the kitchen inaccessible to the clients. The non-perishable and perishable food supply is sufficient for the clients in care. The facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

LPA reviewed two (2) client files for admission agreements, updated physician reports, and needs and services plans. LPA reviewed three (3) staff files for First Aid/CPR certifications, criminal record clearances, trainings, and health screenings.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

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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Document Has Been Signed on 03/14/2024 01:12 PM - It Cannot Be Edited

Created By: Ryan Gardner On 03/14/2024 at 11:54 AM

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: NOAH'S ARK ADULT HOME	FACILITY NUMBER: 331881043
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80075(f)

80075 Health Related Services (f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	This requirement is not met as evidenced based on interview and document review, the licensee did not comply with the section cited above evidenced by Staff S1 not receiving training in first aid from persons qualified by agencies including but not limited to the American Red Cross which poses a potential health, safety, or personal rights risk to persons in care.
	POC Due Date: 03/15/2024
	Plan of Correction
1 2 3 4	The licensee has agreed to read regulation 80075 entirely and send LPA a statement of understanding that the regulation was read and understood. The licensee has agreed to have Staff S1 complete training by the POC due date and send proof to LPA. POC is due by 3/15/2024.

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

LICENSING EVALUATOR NAME:

Ryan Gardner

LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024

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

FACILITY NAME: NOAH'S ARK ADULT HOME	FACILITY NUMBER: 331881043
	VISIT DATE: 03/14/2024

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During file review, LPA found that Staff S1 does not have a First Aid/CPR certification. The facility will be issued a deficiency.

Based on the observations made during today’s visit, one (1) deficiency was cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809), LIC809D, and LIC811 were discussed and provided to Administrator Ruth Anguiano, along with a copy of the appeal rights.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024

LIC809 (FAS) - (06/04)

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