336410692-12-8-2023-56-AS-RGAR-CYBQXL-20231208113339

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336410692
Report Date: 12/08/2023
Date Signed: 12/08/2023 11:33:50 AM

Document Has Been Signed on 12/08/2023 11:33 AM - 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:	EASTVALE MEADOWS		FACILITY NUMBER:	336410692
ADMINISTRATOR:	SIMM SANASINH		FACILITY TYPE:	740
ADDRESS:	6885 CEDAR CREEK ROAD		TELEPHONE:	(951) 520-1074
CITY:	CORONA	STATE: CA	ZIP CODE:	92880
CAPACITY:	6	CENSUS: 6	DATE:	12/08/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Amelia Rodriguez- Caregiver		TIME COMPLETED:	11:43 AM

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	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 Caregiver Amelia Rodriguez 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 Caregiver 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 provides care to residents with dementia which requires auditory alarms on the facility exit doors. The facility will be issued a deficiency for not having an auditory alarm on the facility exit door in resident bedroom number one (1). 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 bathroom to be at 112.4 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, labor laws, 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 and staff files. Medications are kept inside the kitchen inaccessible to residents. LPA found that Resident’s R1, R3, R6, and an unknown resident’s medications were being stored in plastic storage containers. The facility will be issued a deficiency for not storing the resident’s medications in the original medication containers. LPA found that the bathroom closet is being used for sleeping arrangements for the facility staff. The bathroom closet contains a bed, a nightstand, and sleeping arrangements for the facility staff.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023

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 12/08/2023 11:33 AM - 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: EASTVALE MEADOWS	FACILITY NUMBER: 336410692
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/08/2023

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
1 2 3 4	This requirement is not met as evidenced based on interview and observation, the licensee did not comply with the section cited above evidenced by storing R1, R3, R6, and an unknown resident’s medication in plastic storage containers which poses an immediate health, safety, or personal rights risk to persons in care.
	POC Due Date: 12/09/2023
	Plan of Correction
1 2 3 4	The licensee has agreed to read regulation 87465 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to conduct a medication training with the facility staff and send LPA proof of staff attendance by the POC due date. POC is due by 12/9/2023.

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 Malagon	TELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023

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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: EASTVALE MEADOWS	FACILITY NUMBER: 336410692
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

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	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 having a medical assessment completed for R5 which poses a potential health, safety, or personal rights risk to persons in care.
	POC Due Date: 12/22/2023
	Plan of Correction
1 2 3 4	The licensee has agreed to read regulation 87458 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to have a medical assessment completed for R5 and send LPA proof by the POC due date. POC is due by 12/22/2023.

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
1 2 3 4	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 having a needs and services plans completed for R1, R2, R3, R4, and R5 which poses a potential health, safety, or personal rights risk to persons in care.
	POC Due Date: 12/11/2023
	Plan of Correction
1 2 3 4	The licensee has agreed to read HSC code 1569.695 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to complete needs and services plans for R1, R2, R3, R4, and R5, and send LPA proof by the POC due date. POC is due by 12/11/2023.

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	TELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/08/2023 11:33 AM - 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: EASTVALE MEADOWS	FACILITY NUMBER: 336410692
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(a)

87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	This requirement is not met as evidenced by observation and interview, the licensee did not comply with the section cited above by allowing staff to have a bed and sleeping arrangements in the bathroom closet which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/11/2023
	Plan of Correction
1 2 3 4	The licensee has agreed to read regulation 87307 entirely and send LPA self-certify letter that the regulation was read and understood. The licensee has agreed to vacate the staff bed and staff sleeping arrangements out of the bathroom closet. The licensee has agreed to send LPA pictures of the bathroom closet to verify the staff bed and staff sleeping arrangements have been moved out of the bathroom closet. POC is due by 12/11/2023.

Type B

Section Cited

CCR

87705(j)

87705 Care of Persons with Dementia (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	This requirement is not met as evidenced based on interview and observation, the licensee did not comply with the section cited above evidenced by not having an auditory device on the facility exit door in resident room one (1) which poses a potential health, safety, or personal rights risk to persons in care.
	POC Due Date: 12/11/2023
	Plan of Correction
1 2 3 4	The licensee has agreed to read regulation 87705 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to install auditory devices on all facility exits. POC is due by 12/11/2023.

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	TELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/08/2023 11:33 AM - 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: EASTVALE MEADOWS	FACILITY NUMBER: 336410692
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(c)(5)

87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	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 having an annual medical assessment completed for R1, R3, and R4 which poses a potential health, safety, or personal rights risk to persons in care.
	POC Due Date: 12/22/2023
	Plan of Correction
1 2 3 4	The licensee has agreed to read regulation 87705 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to have medical assessments completed for R1, R3, and R4, and send LPA proof by the POC due date. POC is due by 12/22/2023.

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 Malagon	TELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023

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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: EASTVALE MEADOWS	FACILITY NUMBER: 336410692
	VISIT DATE: 12/08/2023

NARRATIVE

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The facility will be issued a deficiency for converting the bathroom closet into a sleeping area for the staff.

Food Service: Non-perishable and perishable food supply is sufficient for the residents in care.

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

Record Review: LPA reviewed six (6) residents files for admission agreements, updated physician reports, and needs and services plans. LPA found that Resident R5 does not have physician’s report/medical assessment completed. The physician’s report/medical assessment in R5’s file was blank and not completed by a physician. The facility will be issued a deficiency for not having a physician’s report/medical assessment completed for R5. LPA found that Resident’s R1, R3, and R4 have a qualifying condition that requires an annual physician’s report/medical assessment. Resident R1’s most recent physician’s report/medical assessment was completed on 11/15/2022, Resident R3’s most recent physician’s report/medical assessment was completed on 1/16/2020, and Resident R4’s most recent physician’s report/medical assessment was completed on 12/5/2022. The facility will be issued a deficiency for not having an annual physician’s report/medical assessment was completed for R1, R3, and R4. LPA found that Resident’s R1, R2, R3, R4, and R5 do not have a needs and services plan completed. The facility will be issued a deficiency for not having needs and services plan completed for Resident’s R1, R2, R3, R4, and R5. LPA reviewed three (3) staff files for First Aid/CPR certifications, criminal record clearances, trainings, and health screenings.

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

An exit interview was conducted, and this report (LIC809), LIC809D forms, and LIC811 were discussed and provided to Caregiver Amelia Rodriguez, along with a copy of the appeal rights.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023

LIC809 (FAS) - (06/04)

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