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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336409060
Report Date: 04/05/2024
Date Signed: 04/05/2024 01:22:59 PM


Document Has Been Signed on 04/05/2024 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:INSPIRATIONS HOME CARE IIIFACILITY NUMBER:
336409060
ADMINISTRATOR:GARCIA, NOELIAFACILITY TYPE:
740
ADDRESS:2685 COTTAGE DRTELEPHONE:
(951) 898-8431
CITY:CORONASTATE: CAZIP CODE:
92881
CAPACITY:6CENSUS: 6DATE:
04/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Romulo Garcia- StaffTIME COMPLETED:
01:35 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 Staff Romulo Garcia and was granted entry to the facility.

The facility is a Residential Care Facility for the Elderly (RCFE) licensed for a capacity of six (6) non-ambulatory residents. The current census is six (6) residents. LPA was accompanied by Staff to conduct a general overall inspection, which included, but was not limited to, the following:

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 bathrooms 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, 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 files and staff files. The medications are kept inside a kitchen cabinet inaccessible to residents. The non-perishable and perishable food supply is sufficient for the residents in care. The pool and spa in the backyard is gated, locked, and secured.

LPA reviewed six (6) residents files for admission agreements, updated physician reports, and needs and services plans. During file review, LPA found that Residents R1, R2, R3, R4, R5, and R6 do not have needs and services plans. The facility will be issued a deficiency for not having needs and services plans completed for the residents. LPA reviewed five (5) staff files for First Aid/CPR certifications, criminal record clearances, trainings, and health screenings.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2024
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 3


Document Has Been Signed on 04/05/2024 01:22 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 III
FACILITY NUMBER: 336409060

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/05/2024

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
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This requirement is not met as evidenced based on interview and document review, the licensee did not comply with the section cited above evidenced by not completing a needs and services plan for Resident’s R1, R2, R3, R4, R5, and R6 which poses a potential health, safety, or personal rights risk to persons in care.
POC Due Date: 04/10/2024
Plan of Correction
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The licensee has agreed to read HSC code 1569.695 entirely and send LPA a statement of understanding that the regulation was read and understood. The licensee has agreed to complete needs and services plans for the residents by the POC due date. POC is due by 4/10/2024.
Type B
Section Cited
CCR
87705(c)(4)(A)
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 as identified in his/her current appraisal. (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, reappraisal or observation to require awake night supervision.

This requirement is not met as evidenced by:
Deficient Practice Statement
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This requirement is not met as evidenced based on interview, the licensee did not comply with the section cited above evidenced by Staff S1 admitting the facility does not have a staff awake at night. The staff only has a staff on call to help the residents which poses a potential health, safety, or personal rights risk to persons in care.
POC Due Date: 04/08/2024
Plan of Correction
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The licensee has agreed to read regulation 87705 entirely and send LPA a statement of understanding that the regulation was read and understood. The licensee has agreed to have a staff awake at night. The licensee has agreed to send LPA a staff schedule that includes an awake night staff. POC is due by 4/8/2024.
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) 248-8222
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


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 III
FACILITY NUMBER: 336409060
VISIT DATE: 04/05/2024
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During today’s visit, Staff S1 admitted that the facility does not have an awake staff at night. S1 stated that the facility has staff present in the facility, but they are asleep and on call if the residents need assistance. The facility has a resident(R5) that has a condition that requires the staff to be awake at night. The facility will be issued a deficiency for not having an awake staff at night.

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 and LIC811 were discussed and provided to Staff Romulo Garcia, along with a copy of the appeal rights.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3