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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336413086
Report Date: 11/14/2024
Date Signed: 11/14/2024 05:47:44 PM

Document Has Been Signed on 11/14/2024 05:47 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:MC BOARD & CAREFACILITY NUMBER:
336413086
ADMINISTRATOR/
DIRECTOR:		MARIA AGUILARFACILITY TYPE:
740
ADDRESS:24259 BRILLANTE DRIVETELEPHONE:
(951) 813-2143
CITY:WILDOMARSTATE: CAZIP CODE:
92595
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
11/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Licensee/Administrator Maria AguilarTIME VISIT/
INSPECTION COMPLETED:
05:45 PM
NARRATIVE
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On 11/14/2024 at 10:30 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 a staff and was granted entry to the facility. At the time of the visit there were two (2) staff present, and five (5) residents present. Licensee/Administrator Maria Aguilar was contacted and informed of the visit. Licensee/Administrator Aguilar arrived during the visit. LPA Brown explained the purpose of the visit to Licensee/Administrator Aguilar.

The facility is a six (6) bedroom, two (4) bathroom home with a kitchen/dining area, living room, and an attached garage. The facility is licensed for a capacity of six (6) non-ambulatory residents, one resident (1) can be bedridden. The current census is five (5) residents. LPA Brown was accompanied by Licensee/Administrator Aguilar 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). There are no obstructions to interior passageway, however LPA Brown observed obstructions to exterior passageways as evidenced of broken bed, household appliances, and other woods and metals observed. Deficiency will be issued. The facility is maintained at a comfortable temperature of 73 degrees Fahrenheit. LPA Brown inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA Brown observed sufficient furniture and lighting throughout the facility. LPA Brown measured and observed the water temperature in the residents/staffs shared bathroom to be at 106 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Postings such as the facility license, personal rights, the CCLD complaint poster, ombudsman poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were not kept inaccessible to residents in care as evidenced of two (2) sharp scissors in the kitchen drawer, not locked and accessible to residents in care. ***Continuation in LIC809C*** ***Amended Copy of LIC809**

Efren MalagonTELEPHONE: (951) 202-6356
Melody BrownTELEPHONE: 951-897-2187
DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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 29
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: MC BOARD & CARE
FACILITY NUMBER: 336413086
VISIT DATE: 11/14/2024
NARRATIVE
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Also, LPA Brown observed Resident #4 (R4) has two (2) bottles of cleaning solutions in R4 closet, not locked and accessible to R4. Deficiency will be issued. Moreover, LPA Brown observed the facility fence side gate in disrepair. Deficiency will be issued. LPA Brown observed three (3) window screens in disrepair. Technical Violation will be issued. LPA Brown observed no non-skid mat in Resident #2 (R2) bathroom. Deficiency will be issued. In addition, LPA Brown observed no night lights maintained in hallways and passages to non-private bathrooms. Deficiency will be issued. Furthermore, LPA Brown observed that the facility added one (1) room in the living room and per documents review and staff interview, the facility did not obtain a building permit prior to the alteration made at the facility and no letter was submitted to CCLD. Deficiency will be issued. Also, LPA Brown observed first aid kit at the facility but no first aid manual approved by the American Red Cross, the American Medical Association or a state of federal health agency. Deficiency will be issued. There was a designated storage space for resident/staff files. Medications are kept inside the medication cabinet in the kitchen inaccessible to residents, however LPA Brown observed Resident #4 (R4) pre-poured medication at the facility. Deficiency will be issued. In addition, LPA Brown observed Resident #1 (R1) with half bed rail but per documents review and staff interview, R1 does not have a written order from R1 Physician indicating the need for half bed rail for mobility. Deficiency will be issued.

Food Service: Seven (7) days non-perishable and two (2) days perishable food supply observed at the facility.

Care & Supervision: LPA Brown observed that the facility does not have a staff scheduled to work the night shift, awake and on duty as required for facility with dementia residents. Deficiency will be issued.

Record Review: LPA reviewed three (3) resident files for admission agreements, updated physician reports, pre-placement appraisals, needs and services plans and centrally stored medications list. LPA Brown observed that R1, R2 and R3 do not have the required pre-admission appraisal maintained in their facility file. Deficiency will be issued. Moreover, LPA Brown observed that R2 and R3 do not have a completed Preplacement Needs and Services Plan/Care Plan (LIC625) as evidenced of missing resident/responsible party signature in R2 and R3 form LIC625. Deficiency will be issued. To add to that, LPA Brown observed Resident #2 (R2) was admitted at the facility without medical assessment/physician report signed by a physician made within last year. Deficiency will be issued. Also, LPA Brown observed that Resident #2 (R2) Physician Report does not have the required physician's primary diagnosis and secondary diagnosis. 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: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
LIC809 (FAS) - (06/04)
Page: 2 of 29
Document Has Been Signed on 11/14/2024 05:38 PM - It Cannot Be Edited


Created By: Melody Brown On 11/14/2024 at 03:13 PM
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
, CA 92507

FACILITY NAME: MC BOARD & CARE
FACILITY NUMBER: 336413086

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
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.

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 ensuring that the two (2) bottles of cleaning solutions in Resident #4 (R4) closet, are locked and were not accessible to R4cwhich poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/15/2024
Plan of Correction
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2
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4
Licensee stated to gtrain all staff on CCR 87309(a) and submit proof of training log to LPA Brown on Plan of Correction (POC) due date.
Type A
Section Cited
CCR
87412(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) A health screening as specified in Section 87411, Personnel Requirements - General.

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 ensuring that Staff #2 (S2) and Staff #3 (S3) complete the required Health Screening Report which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/15/2024
Plan of Correction
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2
3
4
Licensee stated to submit S2 and S3 medical appointment date to complete the required Health Screening Report to LPA Brown 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
TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME:Melody Brown
TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


LIC809 (FAS) - (06/04)
Page: 3 of 29
Document Has Been Signed on 11/14/2024 05:38 PM - It Cannot Be Edited


Created By: Melody Brown On 11/14/2024 at 03:13 PM
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
, CA 92507

FACILITY NAME: MC BOARD & CARE
FACILITY NUMBER: 336413086

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(a)(12)
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: (12) Hazardous health conditions documents as specified in Section 87411, Personnel Requirements - General.

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 ensuring that Staff #2 (S2) and Staff #3 (S3) complete the required Tuberculosis (TB) test and have the required TB Test result maintained in their facility file which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/15/2024
Plan of Correction
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Licensee stated to submit S2 and S3 medical appointment date to complete the required TB Test with TB Test Result to LPA Brown 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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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) 202-6356
LICENSING EVALUATOR NAME:Melody Brown
TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


LIC809 (FAS) - (06/04)
Page: 4 of 29
Document Has Been Signed on 11/14/2024 05:38 PM - It Cannot Be Edited


Created By: Melody Brown On 11/14/2024 at 03:13 PM
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
, CA 92507

FACILITY NAME: MC BOARD & CARE
FACILITY NUMBER: 336413086

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

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) and Staff #3 (S3) complete the required six (6) hours of dementia training before S2 and S3 work independently with residents which poses an immediate health, safety or personal rights risks to resident in care.
POC Due Date: 11/15/2024
Plan of Correction
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Licensee stated to submit S2 and S3 training schedule to complete the required six (6) hours of dementia training before S2 and S3 work independently with residents to LPA Brown 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
TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME:Melody Brown
TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


LIC809 (FAS) - (06/04)
Page: 5 of 29
Document Has Been Signed on 11/14/2024 05:38 PM - It Cannot Be Edited


Created By: Melody Brown On 11/14/2024 at 03:13 PM
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
, CA 92507

FACILITY NAME: MC BOARD & CARE
FACILITY NUMBER: 336413086

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.626(a)(1)
Other Provisions
(a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff: (1) Twelve hours of dementia care training, six of which shall be completed before a staff member begins working independently with residents, and the remaining six hours of which shall be completed within the first four weeks of employment. All 12 hours shall be devoted to the care of persons with dementia. The facility may utilize various methods of instruction, including, but not limited to, preceptorship, mentoring, and other forms of observation and demonstration. The orientation time shall be exclusive of any administrative instruction.

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 ensuring that Staff #2 (S2) and Staff #3 (S3) complete the required additional six (6) hours of dementia training that must be completed within the first four weeks of employment which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/15/2024
Plan of Correction
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Licensee stated to submit S2 and S3 training schedule to complete the required additional six (6) hours of dementia training that must be completed within the first four weeks of employment to LPA Brown on POC due date.
Incidental Medical and Dental Care Services

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) 202-6356
LICENSING EVALUATOR NAME:Melody Brown
TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


LIC809 (FAS) - (06/04)
Page: 6 of 29
Document Has Been Signed on 11/14/2024 05:38 PM - It Cannot Be Edited


Created By: Melody Brown On 11/14/2024 at 03:13 PM
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
, CA 92507

FACILITY NAME: MC BOARD & CARE
FACILITY NUMBER: 336413086

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by 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 ensuring that Resident #1 (R1), Resident #2 (R2) have the required Centrally Stored Medication List maintained in their facility file which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/15/2024
Plan of Correction
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2
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Licensee stated to obtain R1, and R2 Centrally Stored Medication List and submit to LPA Brown on Plan of Correction (POC) due date.
Type A
Section Cited
CCR
87465(a)(8)(A)
Incidental Medical and Dental Care Services
(8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following: (A) A current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency.

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 ensuring that the facility has the current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/15/2024
Plan of Correction
1
2
3
4
Licensee stated to obtain/purchase a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency and submit proof to LPA Brown 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
TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME:Melody Brown
TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


LIC809 (FAS) - (06/04)
Page: 7 of 29
Document Has Been Signed on 11/14/2024 05:38 PM - It Cannot Be Edited


Created By: Melody Brown On 11/14/2024 at 03:13 PM
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
, CA 92507

FACILITY NAME: MC BOARD & CARE
FACILITY NUMBER: 336413086

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2024

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
Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that medications shall not be gtransferred between containers as evidenced of pre-poured meications observed at the facility for Resident #4 (R4) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/15/2024
Plan of Correction
1
2
3
4
Licensee stated to train all staff on CCR 87465(h)(5) and submit proof to LPA Brown on Plan of Correction (POC) due date.
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 and record review, the licensee did not comply with the section cited above by not obtaining Resident #2 (R2) medical assessment or physician report prior to R2 admission at the facility and must have physician signature made within last year which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/15/2024
Plan of Correction
1
2
3
4
Licensee stated to submit a copy of R2 Physician Report/Medical Assessment to LPA Brown 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
TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME:Melody Brown
TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


LIC809 (FAS) - (06/04)
Page: 8 of 29
Document Has Been Signed on 11/14/2024 05:38 PM - It Cannot Be Edited


Created By: Melody Brown On 11/14/2024 at 03:13 PM
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
, CA 92507

FACILITY NAME: MC BOARD & CARE
FACILITY NUMBER: 336413086

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87633(a)(2)
Hospice Care for Terminally Ill Residents
(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility, when all of the following conditions are met: (2) The licensee remains in substantial compliance with the requirements of this section, with the provisions of the Residential Care Facilities for the Elderly Act (Health and Safety Code Section 1569 et seq.), all other requirements of Chapter 8 of Title 22 of the California Code of Regulations governing Residential Care Facilities for the Elderly, and with all terms and conditions of the waiver.

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 exceeding the approved waiver issued by CCLD as evidenced of three (3) residents observed on hospice care during the visit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/15/2024
Plan of Correction
1
2
3
4
Licensee stated to submit a Hospice Waiver Increase to LPA Brown 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
TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME:Melody Brown
TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


LIC809 (FAS) - (06/04)
Page: 9 of 29
Document Has Been Signed on 11/14/2024 05:38 PM - It Cannot Be Edited


Created By: Melody Brown On 11/14/2024 at 03:13 PM
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
, CA 92507

FACILITY NAME: MC BOARD & CARE
FACILITY NUMBER: 336413086

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that there's a staff scheduled to work the night shift, awake and on duty as required for facility with dementia residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/15/2024
Plan of Correction
1
2
3
4
Licensee stated to schedule a staff to work the night shift and submit an updated Personnel Report (LIC500) to LPA Brown on Plan of Correction (POC) due date.
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

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 two (2) sharp scissors observed in the kitchen cabinet 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: 11/15/2024
Plan of Correction
1
2
3
4
Licensee stated to train all staff on CCR 87705(f)(1) and submit training log to LPA rown 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
TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME:Melody Brown
TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


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Page: 10 of 29
Document Has Been Signed on 11/14/2024 05:38 PM - It Cannot Be Edited


Created By: Melody Brown On 11/14/2024 at 03:13 PM
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
, CA 92507

FACILITY NAME: MC BOARD & CARE
FACILITY NUMBER: 336413086

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(5)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers.

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 ensuring that there's a non-skid mat in Resident #2 (R2) bathroom which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/21/2024
Plan of Correction
1
2
3
4
Licensee stated to obtain/purchase non-skid mat and submit proof to LPA Brown on Plan of Correction (POC) due date.
Type B
Section Cited
CCR
87305(a)
Alterations to Existing Buildings or New Facilities
Prior to construction or alterations, all facilities shall obtain a building permit.

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 obtaining the required building permit for the alteration made at the facility as evidenced of one (1) bedroom added in the living room which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/13/2024
Plan of Correction
1
2
3
4
Licensee stated to obtain a building permit and submit a letter to CCLD for the alteration made at the facility and submit copies to LPA Brown 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
TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME:Melody Brown
TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


LIC809 (FAS) - (06/04)
Page: 11 of 29
Document Has Been Signed on 11/14/2024 05:38 PM - It Cannot Be Edited


Created By: Melody Brown On 11/14/2024 at 03:13 PM
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
, CA 92507

FACILITY NAME: MC BOARD & CARE
FACILITY NUMBER: 336413086

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(5)
Personal Accommodations and Services
(5) Night lights shall be maintained in hallways and passages to nonprivate bathrooms.

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 night lights are mainatined in hallways and passages to nonprivate bathrooms which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/21/2024
Plan of Correction
1
2
3
4
Licensee stated to obtain/purchase night lights and submit proof to LPA Brown on Plan of Correction (POC) due date.
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

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 there's no obstructions to exterior passageways as evidenced of broken bed, household appliances, and other woods and metals observed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/21/2024
Plan of Correction
1
2
3
4
Licensee stated to remove the obstructions observed at exterior passageways and submit proof to LPA Brown 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
TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME:Melody Brown
TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/14/2024 05:38 PM - It Cannot Be Edited


Created By: Melody Brown On 11/14/2024 at 03:13 PM
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
, CA 92507

FACILITY NAME: MC BOARD & CARE
FACILITY NUMBER: 336413086

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87456(a)(2)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal.

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 performing the required Pre-Admission Appraisal for Resident #1 (R1), Resident #2 (R2) and Resident #3 (R3) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/21/2024
Plan of Correction
1
2
3
4
Licensee stated to submit a completed copies of R1, R2 and R3 Pre-Admission Appraisal to LPA Brown on Plan of Correction (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
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) and Resident #3 (R3) have the required Preplacement Needs and Services Plan which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/21/2024
Plan of Correction
1
2
3
4
Licensee stated to submit completed copies of R2 and R3 Preplacement Needs and Serv ices Plan to LPA Brown 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
TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME:Melody Brown
TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


LIC809 (FAS) - (06/04)
Page: 13 of 29
Document Has Been Signed on 11/14/2024 05:38 PM - It Cannot Be Edited


Created By: Melody Brown On 11/14/2024 at 03:13 PM
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
, CA 92507

FACILITY NAME: MC BOARD & CARE
FACILITY NUMBER: 336413086

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(b)(1)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by 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 ensuring that Resident #1 (R1) has the complete Physician Report with the required primary diagnosis and secondary diagnosis which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/21/2024
Plan of Correction
1
2
3
4
Licensee stated to submit a completed copy of R1 Physician Report with primary and secondary diagvnosis to LPA Brown on Plan of Correction (POC) due date.
Type B
Section Cited
CCR
87458(b)(5)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (5) The determination whether the person is ambulatory or nonambulatory as defined in Section 87101(a) or (n), or bedridden as defined in Section 87455(d). The assessment shall indicate whether nonambulatory status is based upon the resident's physical condition, mental condition or both.

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 ensuring that Resident #1 (R1) and Resident #3 (R3) have a complete Physician Report with the required ambulatory status which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/21/2024
Plan of Correction
1
2
3
4
Licensee stated to submit copies of R1 and R3 completed physician report with the required ambulatory status to LPA Brown 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
TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME:Melody Brown
TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


LIC809 (FAS) - (06/04)
Page: 14 of 29
Document Has Been Signed on 11/14/2024 05:38 PM - It Cannot Be Edited


Created By: Melody Brown On 11/14/2024 at 03:13 PM
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
, CA 92507

FACILITY NAME: MC BOARD & CARE
FACILITY NUMBER: 336413086

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(a)(2)
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: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage.

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 ensuring that the facility has the required emergency supplies, emergency food and emergency water which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/15/2024
Plan of Correction
1
2
3
4
Licensee stated to obatin/purchase the required emergency supplies/food/water and submit proof to LPA Brown 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 drill at the facility at least quarterly which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/21/2024
Plan of Correction
1
2
3
4
Licensee stated to conduct the required Emergency Drill and submit proof to LPA Brown 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
TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME:Melody Brown
TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


LIC809 (FAS) - (06/04)
Page: 15 of 29
Document Has Been Signed on 11/14/2024 05:38 PM - It Cannot Be Edited


Created By: Melody Brown On 11/14/2024 at 03:13 PM
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
, CA 92507

FACILITY NAME: MC BOARD & CARE
FACILITY NUMBER: 336413086

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(d)
Other Provisions
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary.

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 reviewing the plan annually and not signing the Emergency Disaster Plan as required with signature date which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/21/2024
Plan of Correction
1
2
3
4
Licensee stated to review, sign and date the required Emergency Disaster Plan and submit a copy to LPA Brown on Plan of Correction (POC) due date.
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 and record review, the licensee did not comply with the section cited above aloowing Resident #1 (R1) to have a half bed rail and not ensuring that R1 has a written order from R1 Physician indicating the need for half bed rail for mobility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/15/2024
Plan of Correction
1
2
3
4
Licensee removed R1's bed rail during the visit. POC cleared.
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) 202-6356
LICENSING EVALUATOR NAME:Melody Brown
TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


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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: MC BOARD & CARE
FACILITY NUMBER: 336413086
VISIT DATE: 11/14/2024
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
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32
Also, LPA Brown observed Resident #1(R1) and Resident #3 (R3) Physician Report (LIC602) were incomplete as evidenced of missing ambulatory status of R1 and R3 in their form LIC602. Deficiency will be issued. LPA Brown observed that Resident #1 (R1) and Resident #2 (R2) do not have record of dosages of their medications that are centrally stored maintained at the facility. Deficiency will be issued. LPA reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test results. LPA Brown observed that Staff #2 (S2) and Staff #3 (S3) do not have the required Health Screening Report. Deficiency will be issued. LPA Brown observed that S2 and S3 do not have the required Tuberculosis (TB) Test and TB Test Result. Deficiency will be issued. LPA Brown observed that S2 and S3 did not receive the required training in First Aid from persons qualified by such agencies as the American Red Cross.LPA Brown observed that S2 and S3 did not complete the required six (6) hours of dementia training before S2 and S3 work independently with residents. Deficiency will be issued. LPA Brown observed that S2 and S3 Deficiency will be issued. did not complete the required remaining six (6) hours within the first four (4) weeks of employment. Deficiency will be issued.

During medication audit, LPA Brown observed that staff at the facility did not assist Resident #1 (R1) twelve (12) medications, Resident #2 (R2) three (3) medications for one (1) day and Resident #3 (R3) eight (8) medications for three (3) days and three (3) medications for eleven (11) days. Deficiency will be issued.


Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809), LIC809D, LIC9102 and Appeal Rights were discussed and provided to LIcensee/Administrator Maria Aguilar.

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

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
LIC809 (FAS) - (06/04)
Page: 26 of 29
Document Has Been Signed on 11/14/2024 05:38 PM - It Cannot Be Edited


Created By: Melody Brown On 11/14/2024 at 04:59 PM
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
, CA 92507

FACILITY NAME: MC BOARD & CARE
FACILITY NUMBER: 336413086

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
CCR 87303(a) Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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 ensuring that the facility side fence gate is in good repair which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/21/2024
Plan of Correction
1
2
3
4
Licensee stated to repair the facility side fence gate and submit proof to LPA Brown on 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 Malagon
TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME:Melody Brown
TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


LIC809 (FAS) - (06/04)
Page: 27 of 29
Document Has Been Signed on 11/14/2024 05:38 PM - It Cannot Be Edited


Created By: Melody Brown On 11/14/2024 at 05:18 PM
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
, CA 92507

FACILITY NAME: MC BOARD & CARE
FACILITY NUMBER: 336413086

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(c)(1)
87411 Personnel Requirements – General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

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 ensurimng that Staff #2 (S2) and Staff #3 (S3) receive the required First Aid Training from persons qualified by such agencies as the American Red Cross which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/15/2024
Plan of Correction
1
2
3
4
LIcensee stated to submit S2 and S3 proof of regiustration to complete the required First Aid Training from persons qualified by such agencies as the American Red Cross to LPA Brown on 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 Malagon
TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME:Melody Brown
TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


LIC809 (FAS) - (06/04)
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