336408225-9-26-2024-56-AS-BMAN-D9H3KC-20240926181856

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336408225
Report Date: 09/26/2024
Date Signed: 09/26/2024 06:19:21 PM

Document Has Been Signed on 09/26/2024 06:19 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:	CLARISSA'S HOME CARE		FACILITY NUMBER:	336408225
ADMINISTRATOR:	CASIMIRO JOSE, JR.		FACILITY TYPE:	740
ADDRESS:	2667 CHERRYBARK LANE		TELEPHONE:	(951) 278-1045
CITY:	CORONA	STATE: CA	ZIP CODE:	92881
CAPACITY:	6	CENSUS: 5	DATE:	09/26/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:10 PM
MET WITH:	Casimiro Jose, Licensee/Administrator		TIME COMPLETED:	06:30 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 09/26/2024 at 2:10 PM, Licensing Program Analyst (LPAs) Melody Brown and Becky Mann made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPAs Brown and Mann met with a staff and was granted entry to the facility. At the time of the visit there was one (1) staff present, and five (5) residents present. Licensee/Administrator Casimiro Jose was contacted and informed of the visit. Licensee/Administrator Jose arrived during the visit. LPAs Brown and Mann explained the purpose of the visit to Licensee/Administrator Jose.

The facility is a 4 bedroom, 2 bathroom home with a kitchen/dining area, living room, activity room and laundry area. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) residents of which one (1) maybe bedridden. The facility has four (4) Hospice Waiver. The current census is five (5) residents. LPAs Brown and Mann was accompanied by Staff #2 (S2) 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 Division (CCLD). LPAs Brown and Mann observed no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 70 degrees Fahrenheit. LPAs Brown and Mann inspected resident bedrooms; they are equipped with required furniture such as: mattresses, lamps and storage space. LPAs Brown and Mann observed sufficient lightning. Moreover, LPAs Brown and Mann observed that bathrooms were clean, and appliances were operating appropriately. LPAs Brown and Mann observed grab bars and non-skid mat in the resident bathrooms.

During the tour of the facility, LPAs observed the multiple cans of paints, chemicals and nails in the outside cabinet were not locked and accessible to residents in care. Deficiency will be issued.

***Continuation in LIC 809C***

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Becky Mann	TELEPHONE: 951-248-0306
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024

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 6

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: CLARISSA'S HOME CARE	FACILITY NUMBER: 336408225
	VISIT DATE: 09/26/2024

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
26
27
28
29
30
31
32

***Continuation from LIC809 ***
Also, LPAs Brown and Mann observed Resident #1 (R1) with half bed rails. Licensee/Administrator Casimiro reported to LPAs Brown and Mann that R1 does not have written order from R1 physician indicating the need for half bed rail for mobility. Deficiency will be issued. LPAs Brown and Mann observed sufficient furniture and lighting throughout the facility. LPA Brown and Mann measured and observed the water temperatures in the bathroom to be at 118 degrees Fahrenheit. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCLD complaint poster, Ombudsman Poster and the Emergency Disaster plan were posted in a common area.

There was a designated storage space for resident/staff files. There is a cabinet with the resident’s medications locked in the medication room.

Food Service: Seven (7) days non-perishable and three (3) days perishable food supply observed at the facility.

Care & Supervision: The facility has an administrator present in the facility. LPAs Brown and Mann observed no sufficient number of staff to provide care and supervision to the residents in care due to no staff is scheduled to work the night shift as required for facility with Dementia residents. Deficiency will be issued.

Record Review: LPA reviewed three (3) resident files for admission agreements, updated medical assessment/physician reports, preplacement appraisals. The files were complete with updated physician’s reports, admissions agreements, and preadmissions appraisals. LPAs observed resident #1 (R1) and resident #3 (R3) do not have Preplacement Appraisal maintained in their facility file. Deficiency will be issued. Also, LPAs observed no completed Medical Assessment/Physician Report for resident #2 (R2). Deficiency will be issued. In addition, LPAs reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test results. LPAs observed that files reviewed were complete.

Furthermore, medications were audited for two (2) residents and LPAs observed resident #1 (R1) and resident #2 (R2) medications were not given per R1 and R2 physician's order. Deficiency will be issued.

An exit interview was conducted where this report LIC809, LIC809D, and Appeal Rights were discussed and provided to Licensee/Administrator Casimiro Jose.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Becky Mann	TELEPHONE: 951-248-0306
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024

LIC809 (FAS) - (06/04)

Page: 5 of 6

Document Has Been Signed on 09/26/2024 06:19 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: CLARISSA'S HOME CARE	FACILITY NUMBER: 336408225
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(a)(4)

Incidental Medical and Dental Care Services

(4) The licensee shall assist residents with self-administered medications as needed. 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 by not ensuring that one (1) medication of Resident #1 (R1) and three (3) medications of Resident #2 (R2) were given per their physician's order which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/27/2024
	Plan of Correction
1 2 3 4	Licensee stated to train all staff on CCR 87465(a)(4) and submit proof to LPA Mann at Plan of Correction (POC) due date and Licensee stated that they will utilize Medication Administration Record (MAR) for all their residents.

Type A

Section Cited

CCR

87458(a)

Medical Assessment

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. 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 Resident #2 (R2) has Medical Assessment/Physician Report prior to accepting R2 at the facility on 8/24/24 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/27/2024
	Plan of Correction
1 2 3 4	Licensee stated to submit a medical appointment for R2 to complete the required Medical Assessment/Physician Report to LPA Mann by POC due date.

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: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Becky Mann	TELEPHONE: 951-248-0306
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024

LIC809 (FAS) - (06/04)

Page: 2 of 6

Document Has Been Signed on 09/26/2024 06:19 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: CLARISSA'S HOME CARE	FACILITY NUMBER: 336408225
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87457(c)

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. 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 completing the required Preplacement Appraisal for Resident #1 (R1) and Resident #3 (R3) which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/07/2024
	Plan of Correction
1 2 3 4	Licensee stated to submit Signed Statement of Understanding on CCR 87457(c) to LPA Mann on Plan of Correction (POC) due date.

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. 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 conducting the required Emergency Disaster Drill at least quarterly which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/07/2024
	Plan of Correction
1 2 3 4	Licensee stated to submit proof of completed Emergency Disaster Drill to LPA Mann on POC due date.

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: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Becky Mann	TELEPHONE: 951-248-0306
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024

LIC809 (FAS) - (06/04)

Page: 3 of 6

Document Has Been Signed on 09/26/2024 06:19 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: CLARISSA'S HOME CARE	FACILITY NUMBER: 336408225
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/26/2024

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 allowing Resident #1 (R1) to have half bedrail and no written order from R1 physician indicating the need for half bedrail for mobility which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/07/2024
	Plan of Correction
1 2 3 4	Licensee removed R1 half bed rail during the visit. Plan of Correction (POC) cleared.

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: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Becky Mann	TELEPHONE: 951-248-0306
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024

LIC809 (FAS) - (06/04)

Page: 4 of 6

Document Has Been Signed on 09/26/2024 06:19 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: CLARISSA'S HOME CARE	FACILITY NUMBER: 336408225
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)(1)

87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. 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 multiple cans of paints, chemicals and nails were locked and not accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/27/2024
	Plan of Correction
1 2 3 4	Licensee immediately locked the observed cans of paints, chemicals and nails during the visit. Licensee stated to train all staff on CCR 87309(a)(1) and submit staff training log to LPA Mann on Plan of Correction (POC) due date.

Type A

Section Cited

CCR

87705(c)(4)(A)

87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs... (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 through a pre-admission appraisal... 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 having a staff scheduled to work the night shift as required for facility with Dementia residence which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/27/2024
	Plan of Correction
1 2 3 4	Licensee stated to schedule a staff to work the night shift as required for facility with Dementia residence and submit an updated personnel report (LIC 500) to LPA Mann on POC due date.

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: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Becky Mann	TELEPHONE: 951-248-0306
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024

LIC809 (FAS) - (06/04)

Page: 6 of 6