336402005-11-7-2023-56-AS-RGAR-CXCSAR-20231107124246

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336402005
Report Date: 11/07/2023
Date Signed: 11/07/2023 12:52:52 PM

Document Has Been Signed on 11/07/2023 12:52 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:	INSPIRATIONS HOME CARE		FACILITY NUMBER:	336402005
ADMINISTRATOR:	GARCIA, NOELIA		FACILITY TYPE:	740
ADDRESS:	2755 THACKER DR		TELEPHONE:	(951) 735-6797
CITY:	CORONA	STATE: CA	ZIP CODE:	92881
CAPACITY:	6	CENSUS: 5	DATE:	11/07/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:33 AM
MET WITH:	Noelia Garcia-Administrator		TIME COMPLETED:	01:02 PM

NARRATIVE

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Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Administrator Noelia Garcia and was granted entry to the facility. At the time of the visit, there were three (3) staff present and five (5) residents present.

The facility is a four (4) bedroom, two (2) bathroom home with a kitchen, a dining area, a living room area, and an attached garage. The facility is a Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) non-ambulatory residents, four (4) of the six (6) residents may be bedridden. The current census is five (5) residents. LPA was accompanied by Administrator 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 interior and exterior passageways. The facility is maintained at a comfortable temperature. LPA 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 observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperature in the bathroom to be at 106.1 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Postings such as the facility license, personal rights, the CCL complaint poster, labor laws, 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. There was a designated storage space for resident/staff files. Medications are kept inside the medication cabinet in the kitchen inaccessible to residents. LPA discovered that Resident R1 had medications that were pre prepped and being stored in plastic cups. The facility will be issued a type A deficiency for storing R1’s medication outside of the original prescription bottle. Overall, the facility is clean and in good repair.

Food Service: Non-perishable and perishable food supply is sufficient for the residents in care.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

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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Document Has Been Signed on 11/07/2023 12:52 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: INSPIRATIONS HOME CARE	FACILITY NUMBER: 336402005
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(5)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and observation, the licensee did not comply with the section cited above evidenced by having Resident R1’s medications pre prepped and stored outside of the original prescription bottles in plastic cups which poses an immediate health, safety, or personal rights risk to persons in care.
	POC Due Date: 11/08/2023
	Plan of Correction
1 2 3 4	The licensee has agreed to read regulation 87645 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed that moving forward all resident’s medications will be stored in the original prescription bottles. The licensee has agreed to conduct training on the regulation with staff and send LPA documented proof of staff attendance. POC is due by 11/8/2023.

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) 248-8222
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/07/2023 12:52 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: INSPIRATIONS HOME CARE	FACILITY NUMBER: 336402005
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(e)(2)

Other Provisions

(e) A facility shall have all of the following information readily available to facility staff during an emergency: (2) An appraisal of resident needs and services plan for each resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, document review, and observation, the licensee did not comply with the section cited above evidenced not having needs and services plans for three (3) out of three (3) residents files checked which poses a potential health, safety, or personal rights risk to persons in care.
	POC Due Date: 11/10/2023
	Plan of Correction
1 2 3 4	The licensee has agreed to read health and safety code 1569.695 entirely and send LPA a self-certified letter that the code was read and understood. The licensee has agreed that moving forward all resident’s will have a resident needs and services plan in their file. The licensee has agreed to complete a needs and services plan for all the residents and send proof to LPA. POC is due by 11/10/2023.

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) 248-8222
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

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: INSPIRATIONS HOME CARE	FACILITY NUMBER: 336402005
	VISIT DATE: 11/07/2023

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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 three (3) residents files for admission agreements, updated physician reports, and needs and services plans. LPA discovered that three (3) out of three (3) residents files did not have a needs and services plan. The facility will be issued a type B deficiency for not having needs and services plans for the residents. LPA reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. Medications/MARs records were audited and appeared to be dispensed and logged appropriately.

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) and LIC809D forms were discussed and provided to Administrator Noelia Garcia, along with a copy of the appeal rights.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

LIC809 (FAS) - (06/04)

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