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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336409886
Report Date: 08/23/2024
Date Signed: 08/23/2024 12:46:57 PM

Document Has Been Signed on 08/23/2024 12:46 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:NEW LIFE RESIDENCEFACILITY NUMBER:
336409886
ADMINISTRATOR/
DIRECTOR:		ANA MARIA SANTALLAFACILITY TYPE:
735
ADDRESS:7384 HIGH KNOLL CIRCLETELEPHONE:
(951) 737-9323
CITY:CORONASTATE: CAZIP CODE:
92881
CAPACITY: 6CENSUS: 4DATE:
08/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Licensee/Administrator Ana Maria SantallaTIME VISIT/
INSPECTION COMPLETED:
12:50 PM
NARRATIVE
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On 08/23/2024 at 9:10AM, Licensing Program Analysts (LPAS) Raquel Hernandez, Melody Brown and Renese Howell-Small conducted an unannounced visit to the facility to conduct the required comprehensive annual inspection to the facility. LPAs Hernandez, Brown and Small were greeted by a staff and gained access at the home. Licensee/Administrator Ana Maria Santalla was contacted and informed of the visit. LPAs Hernandez, Brown and Small explained the purpose of the visit to Licensee/Administrator Ana Maria Santalla. The facility has five (5) bedrooms, two (2) bathrooms, kitchen, dining room, living room, attached garage, and backyard. The facility is vendorized by Inland Regional Center (IRC). LPAs Hernandez, Brown and Small completed a walkthrough of the facility, review of records, personal and incidental (P&I) and medications audit.


Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD), LPAs Hernandez, Brown and Small observed two (2) clients during the visit. Out of the four (4) clients’ in the community. There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 73 degrees Fahrenheit. LPAs Hernandez, Brown and Small inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, chairs, and sufficient lighting. LPAs Hernandez, Brown and Small inspected client bathrooms; bathrooms were clean, and appliances were found functional. Water temperatures tested at 109 degrees Fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide detectors, charged fire extinguisher, and first aid kit with first aid book. Posters such as; the personal rights, CCLD complaint poster, labor laws, and emergency disaster plan were posted in a common area. Client medications were kept in secure cabinets inaccessible to clients. LPAs Hernandez, Brown and Small observed no night lights in the hallway leading to clients' shared bathrooms. Deficiency will be issued. The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility. **Continuation on LIC809C**
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2024
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: NEW LIFE RESIDENCE
FACILITY NUMBER: 336409886
VISIT DATE: 08/23/2024
NARRATIVE
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Yards/Outside: One shaded patio, one (1) side gate with self-latching handle on the right side of the house that leads into the backyard, attached two (2) car garage observed. All outdoor pathways were free of obstructions.
Food Service: LPAs Hernandez, Brown and Small observed two (2) day(s) supply of perishable food and seven (7) day(s) supply of non-perishables food and snacks. Dishes, cups, and utensils were stored properly.


Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPAs Hernandez, Brown and Small reviewed two (2) client files for admission agreements, updated physician reports, and individual program plan (IPP). LPA's Hernandez, Brown and Small reviewed two (2) client medications were reviewed. LPA Hernandez, Brown and Small also reviewed two (2) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA's Hernandez, Brown and Small observed Staff #2 (S2) did not have a completed First Aid/CPR training. Deficiency will be issued. LPA's Hernandez, Brown and Small observed Staff #3 (S3) did not have a completed required emergency intervention training. Deficiency will be issued. LPA's Hernandez, Brown and Small observed Staff #3 (S3) did not have a completed tuberculosis (TB) test. Deficiency will be issued.

LPA's Hernandez, Brown and Small audited two (2) clients medications and observed that client #1 (C1) one (1) medication not given according to physicians directions as evidenced of per documents review medication was not given since 08/17/2024. Deficiency will be issued. LPA's Hernandez, Brown and Small audited two (2) clients personal and incidental (P&I) and no issues were observed.

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

An exit interview was conducted, this report (LIC809) and (LIC809D) was discussed and provided to Licensee/Administrator Ana Maria Santalla.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 08/23/2024 12:46 PM - It Cannot Be Edited


Created By: Raquel Hernandez On 08/23/2024 at 11:36 AM
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: NEW LIFE RESIDENCE
FACILITY NUMBER: 336409886

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that Staff #3 (S3) complete the required health screening report in S3 file, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/24/2024
Plan of Correction
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Licensee stated to submit to LPA Hernandez medical appointment for S3 to complete the required health screening report/health screening report completed on Plan of Correction (POC) due date.
Type A
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that Staff #3 (S3) complete the required tuburcluosis (TB) test, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/24/2024
Plan of Correction
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Licensee stated to submit to LPA Hernandez medical appointment/completed TB test for S3 on Plan of Correction (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 Malagon
LICENSING EVALUATOR NAME:Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 08/23/2024 12:46 PM - It Cannot Be Edited


Created By: Raquel Hernandez On 08/23/2024 at 11:36 AM
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: NEW LIFE RESIDENCE
FACILITY NUMBER: 336409886

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(5)(B)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that client #1 (C1) one (1) medication not given according to physicians directions as evidenced of per documents review medication was not given since 08/17/2024, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/24/2024
Plan of Correction
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Licensee stated to train all staff on 80075(b)(5)(B) and submit proof to LPA Hernandez by 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 Malagon
LICENSING EVALUATOR NAME:Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 08/23/2024 12:46 PM - It Cannot Be Edited


Created By: Raquel Hernandez On 08/23/2024 at 11:36 AM
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: NEW LIFE RESIDENCE
FACILITY NUMBER: 336409886

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(e)(2)
Fixtures, Furniture, Equipment, and Supplies
(e) Emergency lighting, which shall include at a minimum working flashlights or other battery-powered lighting, shall be maintained and readily available in areas accessible to clients and staff. (2) Night lights shall be maintained in hallways and passages to nonprivate bathrooms.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that the required night lights were maintained in hallways and passages to nonprivate bathrooms, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2024
Plan of Correction
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Licensee stated to obtain/purchase night lights and submit proof to LPA Hernandez on 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 Malagon
LICENSING EVALUATOR NAME:Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2024


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 08/23/2024 12:46 PM - It Cannot Be Edited


Created By: Raquel Hernandez On 08/23/2024 at 11:36 AM
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: NEW LIFE RESIDENCE
FACILITY NUMBER: 336409886

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(f)
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that Staff #2 (S2) completed the required First Aid/CPR Training from persons qualified by agencies including but not limited to American Red Cross, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/24/2024
Plan of Correction
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Licensee stated to submit proof to LPA Hernandez of S2 enrollment/registration or submit the certificate complete for CPR/First Class on POC due date.
Type A
Section Cited
CCR
85165(b)
85165 Emergency Intervention Staff Training (b) Staff who use, participate in, approve or provide visual checks of manual restraint or seclusion, shall have a minimum of sixteen hours of emergency intervention training and be certified...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that Staff #3 (S3) completed the required emergency intervention training, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/24/2024
Plan of Correction
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Licensee stated to submit proof to LPA Hernandez of S3 enrollment/registration or completeed emergency intervention training 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:Efren Malagon
LICENSING EVALUATOR NAME:Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2024


LIC809 (FAS) - (06/04)
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