331881264-1-4-2024-18-AS-SMAZ-CZ6MH7-20240104083701

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881264
Report Date: 12/29/2023
Date Signed: 01/04/2024 08:37:45 AM

Document Has Been Signed on 01/04/2024 08:37 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	BIANCA'S HOME CARE 2		FACILITY NUMBER:	331881264
ADMINISTRATOR:	DAO, BREVET		FACILITY TYPE:	740
ADDRESS:	12432 BOUGAINVILLEA WAY		TELEPHONE:	(714) 507-8040
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92503
CAPACITY:	6	CENSUS: 5	DATE:	12/29/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:19 AM
MET WITH:	Brevet Dao, Administrator		TIME COMPLETED:	05:20 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 Analyst (LPA), Stephanie Martinez, conducted a required annual inspection at Bianca's Home Care 2. The LPA was allowed entrance into the facility by staff member, Norqueza Pabalan, and later met with Administrator, Brevet Dao. The LPA informed the Administrator of the purpose for the visit. The facility currently has an approved Hospice Waiver for six (6) residents. The inspection included the following: interior/exterior inspection and a review of records. Physical Plant: The facility consists of four (4) resident bedrooms, one staff bedroom, two dinning areas, two living spaces, an open kitchen, a laundry room, two garage spaces, and a covered patio with sufficient seating and space for activities. There are no bodies of water located on the property. According to Administrator Dao, no weapons are stored in the home. The facility is being maintained at a comfortable temperature. All outdoor and indoor passageways are kept free of obstruction and are free of debris and other trash. There are grab bars for each toilet, bathtub and shower used by residents. Resident showers have non-skid mats or strips present. The carbon monoxide and smoke detectors were tested by facility staff and were observed to be in operating condition. The LPA observed multiple chemicals accessible to unauthorized individuals throughout the facility; one large bottle of Fabuloso in a storage box under the backyard patio, all purpose cleaner beside the toilet in bathroom #1, Comet, Lysol, Clorox, Ajax, and other cleaners underneath a sink in the laundry room (NOTE: the laundry room was accessible to unauthorized individuals as the door was propped open throughout the LPA's visit). The LPA observed a broken mirror in bathroom #1. The LPA also observed one torn window screen in the back yard near the exit gate, a bent window screen to the right of the backyard patio, and one damaged baseboard near bedroom four. The facility was operating beyond the conditions on the license. Resident Two (R2), whose Physician's Report for Residential Care Facilities for Elderly designates the individual as bedridden. R2 was not residing in a bedridden approved bedroom. In addition, the LPA observed there to be three total residents, who are designated as bedridden on their Physician's Report, to be in care. Resident three (R3) was also not

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie Martinez	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2023

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

FACILITY NAME: BIANCA'S HOME CARE 2	FACILITY NUMBER: 331881264
	VISIT DATE: 12/29/2023

NARRATIVE

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residing in a bedridden approved bedroom. The facility has an approved fire clearance for only two bedridden residents.

Additional violations were observed during the inspection, including, resident records, staff training, and accessibility of medications. Due to insufficient time, a continuation visit will be conducted by the LPA at a later time and violations will cited appropriately. Immediate concerns were addressed with the Administrator during today's inspection.

An exit interview was conducted; this report was reviewed with Administrator Dao and a copy was provided along with the LIC 811 and instructions on appeal rights.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie Martinez	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/04/2024 08:37 AM - 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BIANCA'S HOME CARE 2	FACILITY NUMBER: 331881264
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87204(a)

Limitations -Capacity and Ambulatory Status

(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in that one out of two residents was not residing in the designated bedridden room. In addition, it was revealed a total of three bedridden residents were residing in the home; however, the licensee was approved for two bedridden residents only. This poses an immediate health and safety risk to persons in care.
	POC Due Date: 12/30/2023
	Plan of Correction
1 2 3 4	The Administrator stated neither Resident Two (R2) or Three (R3) are bedridden. She stated a re-evaluation of the ambulatory status will be conducted on R2 and R3 by the resident's primary care physicians and updated written Medical Assessments will be submitted to the Department by the 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: Rikesha Stamps	TELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie Martinez	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2023

LIC809 (FAS) - (06/04)

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