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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530128
Report Date: 05/07/2024
Date Signed: 05/07/2024 04:11:48 PM


Document Has Been Signed on 05/07/2024 04:11 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:EARLY BIRD CARE HOMEFACILITY NUMBER:
335530128
ADMINISTRATOR:CHANTHARASETH,PATSARAFACILITY TYPE:
740
ADDRESS:11860 CONFLUENCE DRTELEPHONE:
(657) 722-9269
CITY:JURUPA VALLEYSTATE: CAZIP CODE:
91752
CAPACITY:6CENSUS: 2DATE:
05/07/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Licensee/Administrator Patsara ChantharasethTIME COMPLETED:
04:20 PM
NARRATIVE
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On 05/07/2024 at 01:30 PM, Licensing Program Analyst (LPAs) Melody Brown and Sarina Ramirez met with Licensee/Administrator Patsara Chantharaseth to initiate Case Management Visit. The investigation consisted of observation, interviews, and a review of pertinent documentation.

During the facility visit today, 05/07/2024, Licensing Program Analysts (LPA) Melody Brown and Sarina Ramirez requested a copy of the facility’s Personnel Report (LIC500) and LPAs Brown and Ramirez reviewed document received and cross reference Guardian database and observed that Staff #2 (S), and Staff #3 (S3) have their background clearance, but they were not associated to the facility as their criminal background clearance was not transferred to the facility. Moreover, during the facility visit today, 05/07/2024, LPAs Brown and Ramirez informed Licensee/Administrator Chantharaseth that deficiency will be issued and Civil Penalties were assessed during the facility visit today with the amount of $300.00 for S2 and $200.00 for S3 and will continue to be assessed of $100.00 per day per citation until corrected for not transferring criminal record clearance for S2 and S3 for not S2 and S3 criminal background clearance to the facility.

In addition, during the tour of the facility, LPAs Brown and Ramirez observed two (2) beds set-up in the common area of the home. LPAs Brown and Ramirez explained to Licensee/Administrator Chantharaseth that no room commonly used for other purposes shall be used as sleeping room. Deficiency will be issued.

Furthermore, LPAs Brown and Ramirez observed that no staff's schedule to work at night shift and per documents review, the facility has a dementia resident and LPAs observed no night supervision at the facility. Deficiency will be issued.

An exit interview was conducted where this report (LIC809), LIC809D, LIC421BG and Appeal Rights were discussed and provided to Licensee/Administrator Patsara Chantharaseth.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2024
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 3


Document Has Been Signed on 05/07/2024 04:11 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: EARLY BIRD CARE HOME
FACILITY NUMBER: 335530128

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/17/2024
Section Cited
CCR
87355(e)(2)

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87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing... (2) Request a transfer of a criminal record clearance...This requirement is not met as evidenced by:
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Licensee stated to transfer S2 and S3 criminal bacjground clearance to the facility and submit proof to LPA Brown on Plan of Correction (POC) due date.
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Based on observation, interviews and records review, the Licensee did not comply with the section cited above by not transferring Staff #2 (S2) and Staff #3 (S3) criminal background clearance to the facility before allowing S2 and S3 to work at the facility which pose potential safety risks to residents in care.
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Type B
05/17/2024
Section Cited
CCR87307(a)(2)(B)

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87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy... (2) Resident bedrooms shall be provided which meet, at a minimum,...(B) No room commonly used for other purposes shall be used as a sleeping room... This requirement is not met as evidenced by:
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Licensee stated to transfer staffs sleeping area to a bedroom and submit proof to LPA Brown on POC due date.
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Based on observation, interviews and records review, the Licensee did not comply with the section cited above by using the common room as a sleeping area for staffs which poses potential health, safety and personal rights risks to resident in care.
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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 MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 05/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 05/07/2024 04:11 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: EARLY BIRD CARE HOME
FACILITY NUMBER: 335530128

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/08/2024
Section Cited
CCR
87705(c)(4)(A)

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87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia...(4) There is an adequate number of direct care staff to support...(A) In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined... This requirement is not met as evidenced by:
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Licensee stated to schedule a staff to work on a night shift for night supervision and submit proof of updated staff schedule or Personnel Summary (LIC500) to LPA Brown on PLan of Correction (POC) due date.
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Based on observation, interviews and records review, the Licensee did not comply with the section cited above by not scheduling a staff to work on a night shift to provide night supervision to a dementia resident which pose immediate health, safety, and personal rights risks to residents in care.
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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 MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 05/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3