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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336405670
Report Date: 08/26/2021
Date Signed: 08/26/2021 01:22:09 PM

Document Has Been Signed on 08/26/2021 01:22 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
RIVERSIDE, CA 92507
FACILITY NAME:SLB INCORPORATED-MESA TOPFACILITY NUMBER:
336405670
ADMINISTRATOR:LIBERTY HALLFACILITY TYPE:
735
ADDRESS:28331 MESA TOP TRAILTELEPHONE:
(951) 485-6779
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY: 6CENSUS: 3DATE:
08/26/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Michael Hall - AdministratorTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility to deliver findings on an open complaint investigation (#18-AS-20200115104818). LPA Colvin met with Administrator Michael Hall and during LPA Colvin's inspection LPA Colvin observed the following issues which needed to be addressed:
  • Exceptions and Waivers: LPA Colvin observed that R1 has two Restricted Health Conditions, for which the facility had not requested an Exception from Community Care Licensing (CCL). Deficiency cited.

  • Training for Restricted Health Condition: LPA Colvin observed that R1 was admitted back to the facility on 10/16/19 with a colostomy. S1 & S2 worked at the facility in December 2019 and January 2020 (on dates while R1 was present) prior to receiving training on care for the colostomy on 1/24/20. Deficiency cited.

    • Personnel Requirements: LPA Colvin observed that multiple staff members (S1, S2, S3, S4, & S5) worked at the facility (on dates while R1 was present) prior to receiving training on glucose testing. R1 requires assistance with glucose testing. S1, S2, & S3 did not receive training on this until 1/24/20 and S4 & S5 did not have records showing that they had received the training. Deficiency cited.

    • Responsibility for Providing Care and Supervision: Hospital records show that R1's discharge from the hospital was delayed 2 days due to hospital not being able to reach facility Administrator. Deficiency cited.

    • Modifications to Needs and Services Plan: LPA Colvin observed that R1 had numerous hospitalizations from October 2019 to January 2020, where his condition had dramatically changed, such as now having two Restricted Health Conditions. R1's Needs and Services Plan was not updated from 10/1/19 until 1/1/20. Deficiency cited.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2021
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 5
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
RIVERSIDE, CA 92507
FACILITY NAME: SLB INCORPORATED-MESA TOP
FACILITY NUMBER: 336405670
VISIT DATE: 08/26/2021
NARRATIVE
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  • Restricted Health Condition Care Plan: LPA Col observed that R1's Restricted Health Care Plan for the PEG Tube did not include confirmation from Inland Regional Center that the Plan was approved prior to R1 returning to the facility. Deficiency cited.

The facility was cited a deficiency which is detailed on the LIC809D. A copy of this report, LIC809Ds, and appeal rights were provided to Administrator Michael Hall during the exit interview.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 08/26/2021 01:22 PM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Crystal Colvin On 08/26/2021 at 12:11 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: SLB INCORPORATED-MESA TOP
FACILITY NUMBER: 336405670

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
08/27/2021
Section Cited
CCR
8024(b)(2)

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Exceptions and Waivers: (b) The licensing agency shall have the authority to approve the use of alternate concepts...under the following circumstances: (2) The applicant or licensee shall submit to the licensing agency a written request for a waiver or exception... This requirement was not met by:
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Licensee agrees to audit all resident for possbile restricted health conditions and ensure that an exception is on file from CCL for each. Licensee may self-certify to LPA Colvin once complete. Self-Certification due by Plan of Correction date of 8/27/21.
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Based on record review, the Licensee did not comply with the above regulation with at least one resident (R1). R1 had a change of condition resulting in having 2 restricted health conditions (colostomy & PEG tube). Licensee did not request an exeption. This was an immedaite health and safety risk to R1.
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Under Appeal
Type A
08/27/2021
Section Cited
CCR80092.1(f)(2)

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Colostomy/Ileostomy: (f) Prior to admission of a client with a restricted health condition...the licensee shall: (2) Ensure that facility staff who will participate in meeting the client's specialized care needs complete training provided by a licensed professional... This requirement was not met by:
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Licensee agrees to audit all staff records for those who work at facility to ensure all training for residents' in care needs are up to date. Licensee may self-ceritfy to LPA Colvin once complete. Self-Certification due by Plan of Correction date of 8/27/21.
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Based on record review, the Licensee did not comply with the above regulation with at least 2 staff (S1 & S2). S1 & S2 did not receive colostomy training until 1/24/20, but worked at the facility while R1 was present on multiple days (12/13/19, 1/9/20, & 1/10/20). This posed an immediate health and safety risk.
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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:Joel Esquivel
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2021


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 08/26/2021 01:22 PM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Crystal Colvin On 08/26/2021 at 12:46 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: SLB INCORPORATED-MESA TOP
FACILITY NUMBER: 336405670

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/27/2021
Section Cited
CCR
80065(a)

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Personnel Requirements: (a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs. This requirement was not met by:
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Licensee agrees to audit all staff records for those who work at facility to ensure all training for residents' in care needs are up to date. Licensee may self-ceritfy to LPA Colvin once complete. Self-Certification due by Plan of Correction date of 8/27/21.
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Based on record review, the Licensee did not comply with the above regulation with 5 staff (S1 - S5). LPA Colvin observed that 5 staff members worked (December 2019 & January 2020), but did not receive training on glucose testing until 1/24/20. No training records for S4 & S5. This was immediate health risk to R1.
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Under Appeal
Type A
08/27/2021
Section Cited
CCR80078(a)

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Responsibility for Providing Care and Supervision: (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not met as evidenced by:
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No plan of correction required.
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Based on record review, the Licensee did not comply with the above regulation with 1 resident (R1). Hospital records show that R1's discharge from the hospital was delayed 2 days due to hospital not being able to reach facility Administrator. This was an immedaite personal rights violation to R1.
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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:Joel Esquivel
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2021


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 08/26/2021 01:22 PM - It Cannot Be Edited


Created By: Crystal Colvin On 08/26/2021 at 12:47 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: SLB INCORPORATED-MESA TOP
FACILITY NUMBER: 336405670

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/02/2021
Section Cited
CCR
80083(a)

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Modifications to Needs and Services Plan:(a) The licensee shall ensure that each client's written Needs and Services Plan is updated as often as necessary to assure its accuracy, but at least annually. These modifications shall be maintained in the client's file. This requirement was not met as evidenced by:
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Licensee agrees to audit all resident to ensure Needs & Services Plans are up to date. Licensee may self-certify to LPA Colvin once complete. Self-Certification due by Plan of Correction date of 9/2/21.
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Based on record review, the Licensee did not comply with the above regulation with 1 resident (R1). R1 did not have any updated Needs and Services Plan between 10/1/19 and 1/1/20. R1 had surgery for implant of colostomy and PEG Tube in this time. This was a potential health and safety risk to R1.
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Type B
09/02/2021
Section Cited
CCR80092.2(a)(8)

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Restricted Health Condition Care Plan: (a) If the licensee...chooses to care for a client with a restricted health condition,...The plan must include...:(8)...a signed statement from a representative of the placement agency that they have reviewed and approved the plan... This requirement was not met by:
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No plan of correction required
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Based on record review, the Licensee did not comply with the above requirement with at least 1 resident (R1). R1 had a restricted health condition (PEG Tube) but did not have a Plan which included approval from Inland Regional Center. This was a potential health and safety risk for R1.
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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:Joel Esquivel
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2021


LIC809 (FAS) - (06/04)
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