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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530098
Report Date: 10/05/2024
Date Signed: 10/05/2024 02:10:45 PM

Document Has Been Signed on 10/05/2024 02:10 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:COBBLE CREEK HOMEFACILITY NUMBER:
335530098
ADMINISTRATOR/
DIRECTOR:		SANASINH, SIMM K.FACILITY TYPE:
740
ADDRESS:7462 COBBLE CREEK DRTELEPHONE:
(951) 427-1058
CITY:EASTVALESTATE: CAZIP CODE:
92880
CAPACITY: 6CENSUS: 5DATE:
10/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Administrator - Simm SanasinhTIME VISIT/
INSPECTION COMPLETED:
02:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Rico made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Administrator Simm Sanasinh and was granted entry to the facility. Licensed capacity is (6) current census (5). LPA was accompanied by Administrator Simm Sanasinh to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected residents’ 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. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care.

During facility tour, LPA observed the living room located by the front door entrance was converted to R3 bedroom. Based on facility sketched and fire clearance the living room shall remain as a living room not a residents’ bedroom. In addition, LPA observed R1 had bedrails. Based on LIC602A R1 is considered bedridden. During record review, the facility’s fire clearance is granted for (4) ambulatory and (2) non-ambulatory. Facility is not approved for bedridden residents.

Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a variety of food available for clients. Dishes, cups, and utensils were also stored properly.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE: DATE: 10/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2024
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 10/05/2024 02:10 PM - It Cannot Be Edited


Created By: Mary Rico On 10/05/2024 at 01:25 PM
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: COBBLE CREEK HOME
FACILITY NUMBER: 335530098

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(d)(3)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to 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: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review , the licensee did not comply with the section cited above by not having R1 and R2 documented which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2024
Plan of Correction
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The Administrator stated they will create a MAR for R1 and R2 PRN medication and will also train their staff on the regulation cited above.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Mary Rico
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/05/2024 02:10 PM - It Cannot Be Edited


Created By: Mary Rico On 10/05/2024 at 01:25 PM
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: COBBLE CREEK HOME
FACILITY NUMBER: 335530098

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87457(c)(1)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. (1) The appraisal shall include, at a minimum, an evaluation of the prospective resident's functional capabilities, mental condition and an evaluation of social factors as specified in Sections 87459, Functional Capabilities and 87462, Social Factors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having R1 and R2 appraisal which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/11/2024
Plan of Correction
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The Administrator stated they will create an appraisal for R1 and R2. The administrator stated they will also train their staff on the regulation cited above.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Mary Rico
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/05/2024 02:10 PM - It Cannot Be Edited


Created By: Mary Rico On 10/05/2024 at 01:36 PM
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: COBBLE CREEK HOME
FACILITY NUMBER: 335530098

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(2)
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshall, Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city couty, or city and county fire department or district providing fire protectiong services, or the State Fire Marshal: (2)Bedridden persons

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by having (1) bedridden resident which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2024
Plan of Correction
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The lAdministrator has agreed to read regulation 87202 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to find new placement for the (1) bedridden resident. The licensee has agreed to send LPA a plan of new placement.
Type A
Section Cited
CCR
87307(a)(2)(b)
(2) Resident bedrooms shall be provided which meet, at a minimun, the following requirements: (B) No room, commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway,unfinished attic, garage, storage area, shed or similar detached building.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review , the licensee did not comply with the section cited above in by during one of the living room into R3 bedroom which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2024
Plan of Correction
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The Administrator has agreed to read regulation 87202 entirely and send LPA a self-certified letter that the regulation was read and understood. The Administrator has agreed to relocate R3 to a bedroom.
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:Mary Rico
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2024


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: COBBLE CREEK HOME
FACILITY NUMBER: 335530098
VISIT DATE: 10/05/2024
NARRATIVE
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Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPA reviewed (2) resident files for admission agreements, updated physician reports, and needs and services plans. During record review R1 and R2 did not have a preadmission agreement.

Furthermore, during medication audit. LPA observed R1 and R2 had PRN medications. The Administrator did not have documentation of when the PRN was taken. The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.

Lastly, LPA also reviewed (2) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings.

Based on observations today, a civil penalty in the amount of $500.00 dollars will be issued for violation of the facility fire clearance. The facility will be issued (3) Type A deficiencies and (1) Type B deficiency per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809)LIC809D, LIC421IM was discussed and provided to Administrator Simm Sanasinh along with a copy of the appeal rights.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2024
LIC809 (FAS) - (06/04)
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