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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336408394
Report Date: 12/13/2023
Date Signed: 12/13/2023 04:07:23 PM


Document Has Been Signed on 12/13/2023 04:07 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:CUNNINGHAM RESIDENTIAL CARE HOME IIFACILITY NUMBER:
336408394
ADMINISTRATOR:ALICIA CUNINGHAMFACILITY TYPE:
740
ADDRESS:4972 SIERRA VISTATELEPHONE:
(951) 324-1179
CITY:RIVERSIDESTATE: CAZIP CODE:
92505
CAPACITY:12CENSUS: 10DATE:
12/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Alicia CunninghamTIME COMPLETED:
04:10 PM
NARRATIVE
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On 12/13/2023 at 09:00 AM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Brown met with Staff #2 (S2), was granted entry to the facility. At the time of the visit there were three (3) staff present, and six (6) residents present. Administrator Alicia Cunningham was contacted and arrived during the visit.

The facility is a seven (7) bedroom, three (3) bathroom home with a kitchen/dining area, living room and garage. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of twelve (12) residents of which (6) can be non-ambulatory residents and six (6) ambulatory residents. The facility has two (2) Hospice Waiver and side chain links may be locked in evenings. The current census is ten (10) residents. LPA Brown 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 (CCL). LPA Brown observed no obstructions to outdoor passageways. The facility is maintained at a comfortable temperature. LPA Brown 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 Brown observed non-skid mat or strips in the resident bathrooms.

Also, LPA Brown observed Resident #5 (R5) with full bed rails and Administrator Alicia Cunningham reported to LPA Brown that R5 is not on Hospice Care and no written order from the physician was observed indicating the need for postural support/full bed rail. LPA Brown observed no exception letter submitted and approved by Community Care Licensing Division (CCLD) for R5's full bed rails. Deficiency will be issued.

***Continuation in LIC809C ***

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2023
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 12/13/2023 04:07 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: CUNNINGHAM RESIDENTIAL CARE HOME II
FACILITY NUMBER: 336408394

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2023

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
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Based on observation, interview and record review, the licensee did not comply with the section cited above by transferring residents medications/pre-pouring residents medication for the day up to bedtime which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/14/2023
Plan of Correction
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The Licensee stated to train all staff on CCR 87465(h)(5) and submit proof to LPA Brown at Plan of Correction (POC) due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 12/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2023
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: CUNNINGHAM RESIDENTIAL CARE HOME II
FACILITY NUMBER: 336408394

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87355(e)(3)
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 or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by allowing Staff #3 (S3) to work at the facility and not transferring S3's criminal record clearance which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2023
Plan of Correction
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The Licensee stated to transfer S3's criminal record clearance to the facility and submit proof to LPA Brown at Plan of Correction (POC) due date.
Licensee stated to submit Signed Statement of Understanding on CCR 87355(e)(3) to LPA Brown at POC due date.
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
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not completing Appraisal/Needs and Services Plan for Resident #7 (R7) and Resident #8 (R8) which poses a potential health, safety or personal rights risk t by not to persons in care.
POC Due Date: 12/22/2023
Plan of Correction
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The Licensee stated to complete R7 and R8 Appraisal/Needs and Services Plan and submit to LPA Brown at POC due date.
The Licensee stated to submit Signed Statement of Understanding on CCR 87457(c) to LPA Brown at 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: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2023
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: CUNNINGHAM RESIDENTIAL CARE HOME II
FACILITY NUMBER: 336408394

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87219(a)(1)
Planned Activities
(a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. The activities made available shall include: (1) Socialization, achieved through activities such as group discussion and conversation, recreation, arts, crafts, music, and care of pets.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not having planned activities for the month available for the residents which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2023
Plan of Correction
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The Licensee stated to complete a Planned Activities for the month and submit to LPA Brown at Plan of Correction (POC) due date.
Type B
Section Cited
HSC
1569.695(a)
Other Provisions
(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above by not having an emergency and disaster plan at the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2023
Plan of Correction
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The Licensee stated to submit a completed Emergency and Disaster Plan to LPA Brown at POC due date.
The Licensee stated to train all staff on HSC 1569.695(a) and submit proof of Training Log to LPA Brown at 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: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/13/2023 04:07 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: CUNNINGHAM RESIDENTIAL CARE HOME II
FACILITY NUMBER: 336408394

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not conducting the required fire drill and earthquake drill at least quarterly per each shift which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2023
Plan of Correction
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The Licensee stated to train all staff on HSC 1569.695(c) and submit proof of Training Log to LPA Brown at Plan of Correction (POC) due date.
Type B
Section Cited
CCR
87212(c)
Emergency Disaster Plan
(c) Emergency exiting plans and telephone numbers shall be posted.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not having Emergency exiting plans and telephone numbers posted at the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2023
Plan of Correction
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The Licensee stated to train all staff on CCR 87212(c) and submit proof of Training Log to LPA Brown at 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: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/13/2023 04:07 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: CUNNINGHAM RESIDENTIAL CARE HOME II
FACILITY NUMBER: 336408394

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2023

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
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Based on observation, interview and record review, the licensee did not comply with the section cited above by half bed rails for Resident #1 (R1), Resident #2 (R2), and Resident #9 (R9) but no written order from R1, R2 and R9 physician indicating the need for postural support indicating R1, R2 and R9 needed assistance for mobility maintained in R1, R2 and R9 record which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2023
Plan of Correction
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The Licensee stated to submit R1, R2 and R9 Physician written order indicating the need for postural support indicating R1, R2 and R9 needed assistance for mobility to LPA Brown at POC due date.
The Licensee stated to submit Signed Statement of Understanding on CCR 87608(a)(5)(A) to LPA Brown at POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2023
LIC809 (FAS) - (06/04)
Page: 6 of 54


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: CUNNINGHAM RESIDENTIAL CARE HOME II
FACILITY NUMBER: 336408394
VISIT DATE: 12/13/2023
NARRATIVE
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To add to that, LPA Brown observed Resident #1 (R1), Resident #2 (R2), and Resident #9 (R9) have half bed rails but no written order from R1, R2 and R9 physician indicating the need for postural support explaining R1, R2 and R9 needed assistance for mobility maintained in R1, R2 and R9 record. Deficiencies will be issued. LPA Brown observed sufficient furniture and lighting throughout the facility. LPA Brown measured and observed the water temperatures in the bathroom to be at 116 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Personal rights and the Ombudsman poster were observed but no CCL complaint poster and the no disaster plan were posted in a common area. Deficiencies will be issued. LPA Brown observed no available Monthly Activity Calendar at the facility. Deficiencies will be issued.

Moreover, during the tour of the facility, LPA Brown observed that there was a designated storage space for resident/staff files. There is a cabinet with the majority of the resident’s medications locked. However, LPA Brown found medications pre-poured in a partitioned container for the day, up to bedtime medication for each resident at the facility. LPA Brown explained that no medications shall be pre-poured and transferred between containers. The facility will be issued deficiencies for pre-pouring residents medications for the day up to bedtime as this pose immediate health, safety and personal rights risks to residents in care.

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

Care & Supervision: The facility has an administrator present in the facility. LPA Brown observed sufficient number of staff to provide care and supervision to the residents in care.

Record Review: LPA reviewed ten (10) resident files for admission agreements, updated physician reports, and needs and services plans. The files were complete for eight (8) residents with updated physician’s reports, admissions agreements, and Pre-placement appraisals and Appraisal/Needs and Services Plan. However, LPA Brown observed missing Appraisal/Needs and Services Plan for Resident #7 (R7) and Resident #8 (R8). Deficiency will be issued. LPA reviewed four (4) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA found that all staffs have CPR training, staff are properly trained in medication, dementia care, and basic training required for an RCFE. However, LPA Brown observed Staff #3 (S3) criminal background clearance was not transferred to the facility. S3 reported to LPA Brown that S3 started working at the facility 11/28/2023. ***Continuation in LIC809C ***

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023
LIC809 (FAS) - (06/04)
Page: 51 of 54
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: CUNNINGHAM RESIDENTIAL CARE HOME II
FACILITY NUMBER: 336408394
VISIT DATE: 12/13/2023
NARRATIVE
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 LPA Brown informed Administrator Cunningham that deficiency will be issued and civil penalty of $500.00 will be issued during the visit as this pose potential health, safety and personal rights risk to residents in care.

Furthermore, LPA Brown observed no Fire Drill and Earthquake Drill Log or record at the facility and no Infection Control Plan at the facility. Deficiencies will be issued. Also, LPA Brown observed no current edition of a first aid manual approved by American Red Cross, the American Medical Association or a state or federal health agency at the facility. Technical Violation will be issued.

Medications/Medication Administration Records (MARs) records were audited and LPA Brown observed that medications were dispensed for R1 and R9 without record, no December 2023 MAR available for R1 and R9. LPA Brown requested for any record that the facility have for dispensing R1 and R9 December 2023 medications per R1 and R9 physician's order but S3 and Administrator Cunningham reported to LPA Brown that no available record of dispensed medication per R1 and R9 at the facility. Deficiency will be issued.

Based on the observations made during today’s visit, eleven (11) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809), LIC809D, LIC421BG, LIC9102 forms, and Appeal Rights were discussed and provided to Administrator Alicia Cunningham.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023
LIC809 (FAS) - (06/04)
Page: 52 of 54
Document Has Been Signed on 12/13/2023 04:07 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: CUNNINGHAM RESIDENTIAL CARE HOME II
FACILITY NUMBER: 336408394

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(c)
(c) An Infection Control Plan shall be developed by the Licensee and shall be included in the Plan of Operation required by Section 87208.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not having an Infection Control Plan available at the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2023
Plan of Correction
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2
3
4
The Licensee stated to submit a copy of completed Infection Control Plan to LPA Brown at Plan of Correction (POC) due date.
Type B
Section Cited
CCR
87608(a)(5)(B)
87608 Postural Supports (a) Based on the individuals preadmission appraisal...(5) Under no circumstances shall postural supports include...(B) Bed rails that extend the entire length of the bed are prohibited...

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by having a full bed rail for Resident #5 (R5) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2023
Plan of Correction
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2
3
4
The Licensee removed R5 full bed rail during the visit. Plan of Correction (POC) cleared.
The Licensee stated to train all staff on CCR 87608(a)(5)(B) and submit proof to LPA Brown at 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: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2023
LIC809 (FAS) - (06/04)
Page: 53 of 54


Document Has Been Signed on 12/13/2023 04:07 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: CUNNINGHAM RESIDENTIAL CARE HOME II
FACILITY NUMBER: 336408394

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(6)
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not having Resident # 1 (R1) and Resident #9 (R9) Medication Administration Record (MAR) or no record existed at the facility that R1 and R9 medications were dispensed per physicians order which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/14/2023
Plan of Correction
1
2
3
4
The Licensee stated to train all staff on CCR 87465(a)(6) and submit proof of Training Log to LPA Brown at 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 MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2023
LIC809 (FAS) - (06/04)
Page: 54 of 54