335530129-8-26-2024-56-AS-RHEZ-D8J2VM-20240826174408

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 335530129
Report Date: 08/26/2024
Date Signed: 08/26/2024 05:44:23 PM

Document Has Been Signed on 08/26/2024 05:44 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	SENIOR OASIS 2		FACILITY NUMBER:	335530129
ADMINISTRATOR:	APOTROSOAEI, GABRIELA		FACILITY TYPE:	740
ADDRESS:	18780 STATE STREET		TELEPHONE:	(949) 306-8258
CITY:	CORONA	STATE: CA	ZIP CODE:	92881
CAPACITY:	6	CENSUS: 6	DATE:	08/26/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:24 PM
MET WITH:	Licensee Gabriela Apotrosoaei/Administrator Constantin D Apotrosoaei		TIME COMPLETED:	05:50 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 08/26/2024 at 03:24 PM, Licensing Program Analyst (LPA) Raquel Hernandez, Melody Brown and Renese-Howell Small made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection LPA Hernandez, Brown and Small met with Administrator Constantin D Apotrosoaei. At the time of the visit there were two (2) staff present, and six (6) residents present. The facility is a seven (7) 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 six (6) non-ambulatory residents and the current census is six (6) residents. The facility is approved for four (4) hospice waiver. LPA Hernandez, Brown and Small were accompanied by Staff #1 (S1) 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 of 75 degrees. LPA Hernandez, Brown and Small 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 Hernandez, Brown and Small observed sufficient furniture and lighting throughout the facility. LPA Hernandez, Brown and Small measured and observed the water temperature at 107 degrees. 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, 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: Raquel Hernandez	TELEPHONE: 951-248-0336
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024

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 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: SENIOR OASIS 2	FACILITY NUMBER: 335530129
	VISIT DATE: 08/26/2024

NARRATIVE

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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 with the resident’s medications locked. LPA Hernandez, Brown and Small observed 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 Hernandez, Brown and Small reviewed three (3) resident files for admission agreements, updated physician reports, pre-placement appraisals and needs and services plans. LPA Hernandez, Brown and Small observed resident files reviewed were complete. LPA Hernandez, Brown and Small reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with Tuberculosis (TB) test result. During medication audit, LPA's observed three (3) medications of Resident # 2 (R2) were not given per R2's physician order. Deficiency will be issued. Also, LPA's observed bed rail in Resident #2 (R2) room with no written order from R2 physician indicating the need for half-bed rail for mobility. Deficiency will be issued.

Based on the observations made during today’s visit, two (2) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809), LIC809D forms, and Appeal Rights were discussed and provided to Administrator Constantin D Apotrosoaei and Licensee/Administrator Gabriela Apotrosoaei.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Raquel Hernandez	TELEPHONE: 951-248-0336
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/26/2024 05:44 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SENIOR OASIS 2	FACILITY NUMBER: 335530129
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(c)(2)

Incidental Medical and Dental Care Services

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can 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: (2) Once ordered by the physician the medication is given according to the physician's directions. 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 ensuring that three medications (3) of Resident #2 (R2) was given according to physician's directions, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/27/2024
	Plan of Correction
1 2 3 4	Licensee stated to train all staff on CCR 87465(c)(2) and submit proof to LPA Hernandez on Plan of Correction (POC) due date. Also licensee stated to utilize and train staff on Medication Administration Record (MAR) and submit proof of R2 MAR to LPA Hernandez by 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: Raquel Hernandez	TELEPHONE: 951-248-0336
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/26/2024 05:44 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SENIOR OASIS 2	FACILITY NUMBER: 335530129
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87608(a)(5)(A)

Postural Supports

(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. 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 ensuring that the half-bed rail in Resident #2 (R2) room has a written order from R2 physician indicating the need for half-bed rail for mobility, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/06/2024
	Plan of Correction
1 2 3 4	Licensee stated to obtain R2's physician written order indicating the need for half-bed for mobility and submit proof to LPA Hernandez on 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: Raquel Hernandez	TELEPHONE: 951-248-0336
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024

LIC809 (FAS) - (06/04)

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