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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881187
Report Date: 11/22/2023
Date Signed: 11/22/2023 12:49:56 PM


Document Has Been Signed on 11/22/2023 12:49 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:SHAFFER SENIOR CARE, LLCFACILITY NUMBER:
331881187
ADMINISTRATOR:SHALABI, JAMALFACILITY TYPE:
740
ADDRESS:672 SHAFFER STREETTELEPHONE:
(337) 244-2252
CITY:CORONASTATE: CAZIP CODE:
92879
CAPACITY:6CENSUS: 5DATE:
11/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:19 AM
MET WITH:Fadi SuliemanTIME COMPLETED:
01:00 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 Fadi Sulieman was granted entry to the facility.

The facility is a three (3) bedroom, two (2) bathroom home with a kitchen/dining area, living room, and an attached garage. The facility is a Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) ambulatory residents. The current census is five (5) residents. LPA was accompanied by Fadi Sulieman 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). There are no obstructions to interior passageways. There is an obstruction to the exterior garage door. The garage exit door is blocked with wood, a desk pressed against the wood, and an air conditioner placed inside the wood that is blocking the door. The facility will be issued a deficiency for blocking the exit door. The facility is maintained at a comfortable temperature. LPA 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 observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperature in the bathroom to be at 137.4 degrees F. The facility will be issued a deficiency for not having the water temperature within the required range of 105 degrees F and 120 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Postings such as the facility license, personal rights, the CCL complaint poster, labor laws, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to the residents in care. There was a designated storage space for resident/staff files. Medications are kept inside the medication closet in the hallway inaccessible to residents. The facility has a first aid kit stored in the medication closet, but it does not have a first aid manual. The facility will be issued a deficiency for not having a first aid manual.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2023
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


Document Has Been Signed on 11/22/2023 12:49 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: SHAFFER SENIOR CARE, LLC
FACILITY NUMBER: 331881187

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, observation, and document review, the licensee did not comply with the section cited above evidenced by S1 and S2 not having an active CPR certification which poses a potential health, safety, or personal rights risk to persons in care.
POC Due Date: 11/29/2023
Plan of Correction
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The licensee has agreed to read HSC 1569.618 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to have S1 and S2 complete a CPR certification and provide documented proof of the training to LPA by the POC due date. The POC is due by 11/29/2023.
Type B
Section Cited
CCR
87465(a)(8)(A)
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
(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
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Based on interview and observation, the licensee did not comply with the section cited above evidenced by not having a first aid manual which poses a potential health, safety, or personal rights risk to persons in care.
POC Due Date: 11/29/2023
Plan of Correction
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The licensee has agreed to read regulation 87465 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to purchase a first aid manual and send proof to LPA by the POC due date. The POC is due by 11/29/2023.
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) 248-8222
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 11/22/2023 12:49 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: SHAFFER SENIOR CARE, LLC
FACILITY NUMBER: 331881187

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and observation, the licensee did not comply with the section cited above evidenced the water in the bathroom sink being measured at 137.4 F which poses a potential health, safety, or personal rights risk to persons in care.
POC Due Date: 11/29/2023
Plan of Correction
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The licensee has agreed to read regulation 87303 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to adjust the water temperature to the required range by the POC due date. The POC is due by 11/29/2023.
Type B
Section Cited
CCR
87307(d)(6)
(d) The following space and safety provisions shall apply to all facilities:
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and observation, the licensee did not comply with the section cited above evidenced by blocking the garage exit door with wood, a desk pressed against the wood, and an air conditioner placed inside the wood that is blocking the door which poses a potential health, safety, or personal rights risk to persons in care.
POC Due Date: 11/29/2023
Plan of Correction
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The licensee has agreed to read regulation 87307 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed remove the items from blocking the garage exit door by the POC due date. The POC is due by 11/29/2023.
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) 248-8222
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2023
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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SHAFFER SENIOR CARE, LLC
FACILITY NUMBER: 331881187
VISIT DATE: 11/22/2023
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Food Service: Non-perishable and perishable food supply is sufficient for the residents in care.

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

Record Review: LPA reviewed four (4) resident files for admission agreements, updated physician reports, and needs and services plans. LPA reviewed two (2) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA found that Staff S1 and Staff S2 CPR certifications are expired. The facility will be issued a deficiency for S1 and S2 not having active CPR certifications. Medications/MARs records were audited and appeared to be dispensed and logged appropriately.

Based on the observations made during today’s visit, four (4) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809), two (2) LIC809D forms, LIC811 form, and the appeal rights were discussed and provided to Fadi Sulieman.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4