335530063-2-23-2024-56-AS-MBRN-D2QTFF-20240223134128

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 335530063
Report Date: 02/23/2024
Date Signed: 02/23/2024 01:41:45 PM

Document Has Been Signed on 02/23/2024 01:41 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:	SIERRA PINES GUEST HOME		FACILITY NUMBER:	335530063
ADMINISTRATOR:	HAMED, HANAN		FACILITY TYPE:	740
ADDRESS:	5051 LA SIERRA AVE		TELEPHONE:	(786) 219-6008
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92505
CAPACITY:	25	CENSUS: 23	DATE:	02/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Administrator Hanan Hamed		TIME COMPLETED:	01:45 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	On 02/23/2024 at 09:45 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 and was granted entry to the facility. Administrator Hanan Hamed met with LPA Melody Brown during the visit. At the time of the visit there were three (3) staff present, and twenty-three (23) residents present. The facility is a fourteen (14) bedroom, four (4) bathroom home with a kitchen/dining area, living room/activity room. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of twenty-five (25) non-ambulatory residents and approved for six (6) hospice waiver. The current census is twenty-three (23) residents. LPA Brown was accompanied by Administrator Hanan Hamed 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 indoor and 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 sufficient furniture and lighting throughout the facility. LPA Brown measured and observed the water temperatures in the bathroom to be at 106 degrees Fahrenheit. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Fire extinguishers were also observed at the facility. Posters such as personal rights, the CCL complaint poster, Ombudsman poster, labor laws, and the disaster plan were posted in a common area. *Continuation in LIC809C *

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024

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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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: SIERRA PINES GUEST HOME	FACILITY NUMBER: 335530063
	VISIT DATE: 02/23/2024

NARRATIVE

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During the tour of the facility, LPA Brown observed two (2) screen window in disrepair. Deficiency will be issued. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. There is a Medicine Cabinet for the residents with the resident’s medications locked. LPA Brown observed the complete first aid kit and first aid book at the facility.

Food Service: More than seven (7) days’ supply of Non-perishable foods and more than two (2) days’ supply of perishable food supply were observed and sufficient for the number of residents in care.

Care & Supervision: The facility has an Administrator present in the facility with appropriate and enough hours to appropriately manage the facility. The facility has sufficient number of staff to provide care and supervision to the residents in care.

Record Review: LPA Brown reviewed four (4) resident files for admission agreements, updated physician reports, pre-placement appraisals and needs and services plans. LPA Brown observed resident files reviewed were complete. LPA Brown reviewed four (4) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA Brown found that Staff #4 (S4) does not have Health Screening Report with Tuberculosis (TB) Result. Deficiency will be issued. Also, LPA Brown observed S4 did not complete the required 24 hour initial training. Deficiency will be issued. Moreover, Administrator Hamed reported that they have one (1) dementia resident and LPA Brown observed no staff at the facility completed trainings in dementia. Deficiency will be issued. Furthermore, LPA Brown observed no earthquake drill completed at the facility. Last Fire In-Service completed on 10/24/2023 but no Fire Drill completed. Deficiency will be issued. Medications/Medication Administration Record (MAR) were audited, and LPA Brown observed no issue.

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

An exit interview was conducted, and this report (LIC809), LIC809D, LIC9102 forms, and Appeal Rights were discussed and provided to Administrator Hanan Hamed

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/23/2024 01:41 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: SIERRA PINES GUEST HOME	FACILITY NUMBER: 335530063
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)(12)

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: (12) Hazardous health conditions documents as specified in Section 87411, Personnel Requirements - General. 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 having Staff #4 (S4) complete a Health Screening Report and no Tuberculosis (TB) Test result maintained in S4 facility file which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/29/2024
	Plan of Correction
1 2 3 4	Licensee stated to have S4 complete a Health Screening Report and Tuberculosis Test Result and submit proof to LPA Brown at Plan of Correction (POC) due date.

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. 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 having Staff # 2 (S2), Staff #3 (S3) and Staff #4 (S4) complete the required Dementia Training which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/29/2024
	Plan of Correction
1 2 3 4	Licensee stated to have all staff complete the required Dementia Training and submit proof of Training Log to LPA Brow at Plan of Correction (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 Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/23/2024 01:41 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: SIERRA PINES GUEST HOME	FACILITY NUMBER: 335530063
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.69(a)(1)

Other Provisions

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (1) In facilities licensed to provide care for 16 or more persons, the employee shall complete 24 hours of initial training. This training shall consist of 16 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 8 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first four weeks of employment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above by not having Staff #4 (S4) complete the required 24 hours initial training 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	Licensee stated to have S4 complete the required 24 hours initial training and submit proof of Training Log to LPA Brown at Plan of Correction (POC) due date.

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. 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 conducting an eathquake drill at the facility and only completed an In-Service Fire Drill on 10/24/2023 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	Licensee stated to conduct a Fire and Earthquake drill on all shift and submit proof to LPA Brown at Plan of Correction (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 Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/23/2024 01:41 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: SIERRA PINES GUEST HOME	FACILITY NUMBER: 335530063
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(c)

87303 Maintenance and Operation (c) All window screens shall be maintained in good repair. 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 having the windown screen in Room #8 and living Room small window screen in disrepair 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	Licensee stated to submit proof of repaired or replaced window screen in Room #8 and living room small window to LPA Brown at Plan of Correction (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: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024

LIC809 (FAS) - (06/04)

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