336423397-3-8-2024-56-AS-MBRN-D36RUD-20240308121945

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336423397
Report Date: 03/08/2024
Date Signed: 03/08/2024 12:20:19 PM

Document Has Been Signed on 03/08/2024 12:20 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:	HAMNER MANOR		FACILITY NUMBER:	336423397
ADMINISTRATOR:	JAMES VANNOY		FACILITY TYPE:	740
ADDRESS:	7121 MACKINAW CT		TELEPHONE:	(951) 475-5003
CITY:	MIRA LOMA	STATE: CA	ZIP CODE:	91752
CAPACITY:	6	CENSUS: 5	DATE:	03/08/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Licensee/Administrator Lesley Vannoy		TIME COMPLETED:	12:30 PM

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	On 03/08/2024 at 08:30 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 three (3) staff present, and five (5) residents present. Licensee/Administrator Lesley Vannoy was contacted and arrived during the visit. LPA Brown explained the purpose of the visit to Licensee/Administrator Vannoy. The facility is a six (6) bedroom, three (3) bathroom home with a kitchen/dining area, living room, laundry room and detached garage. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) residents of which two (2) can be non-ambulatory residents. The facility has two (2) Hospice Waiver. The current census is five (5) residents. LPA Brown was accompanied by Staff #4 (S4) 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). LPA Brown observed no obstructions to outdoor and indoor passageways. The facility is maintained at a comfortable temperature. LPA Brown inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA Brown observed grab bars and non-skid mat in the resident bathrooms. Also, LPA Brown observed Resident #5 (R5) with full bed rails and Licensee/Administrator Vannoy reported to LPA Brown that R5 is not on Hospice Care and no written order from the physician was observed indicating the need for postural support/full bed rail. LPA Brown observed no exception letter submitted and approved by Community Care Licensing Division (CCLD) for R5's full bed rail. Deficiency will be issued. To add to that, LPA Brown observed Resident #1 (R1), Resident #3 (R3), and Resident #4 (R4) have half bed rails and no written order from their physician indicating the need for half bed rail for mobility. Deficiency will be issued. *Continuation in LIC809C *

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024

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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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: HAMNER MANOR	FACILITY NUMBER: 336423397
	VISIT DATE: 03/08/2024

NARRATIVE

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LPA Brown measured and observed the water temperature in the bathroom to be at 115 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCLD complaint poster and the disaster plan were posted in a common area.

There was a designated storage space for resident/staff files. There is a cabinet with the resident’s medications locked. Moreover, LPA Brown observed one (1) bottle of cleaning supply in the residents' shared bathroom cabinet, not locked and accessible to residents in care. Deficiency will be issued.

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

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

Record Review: LPA reviewed three (3) resident files for admission agreements, updated physician reports, and resident appraisals. The files were complete with updated physician’s reports, admissions agreements, and preadmissions/resident appraisals. LPA reviewed four (4) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) result. LPA found that Staff #6 (S6) working at the facility with criminal background clearance but the facility did not transfer S6 criminal background clearance to the facility. Licensee confirmed to LPA Brown that S6 had been working at the facility since 08/23/2017. Deficiency and civil penalty of $500.00 will be issued during the facility visit today, 03/08/2024 and will continue to be assessed of $100.00 per day until corrected. Furthermore, two (2) residents medication were audited and LPA Brown observed Resident #4 (R4) one (1) medication dispensed and staff did not update R4's dispensed medication in R4 Medication Administration Record (MAR). Deficiency will be issued.

An exit interview was conducted where this report (LIC809), LIC809D, LIC421BG, LIC9102TA and Appeal Rights were discussed and provided to Licensee/Administrator Lesley Vannoy.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/08/2024 12:20 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: HAMNER MANOR	FACILITY NUMBER: 336423397
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(c)(2)

Incidental Medical and Dental Care Services

(c) If the resident's physician has stated in writing that the resident 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 resident with self-administration, provided all of the following requirements are met: (2) 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
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by dispensing Resident #4 (R4) one (1) medication and not updating R4's dispensed medication in R4's Medication Administration Record (MAR) which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/09/2024
	Plan of Correction
1 2 3 4	Licensee stated to train all staff on CCR 87465(c)(2) and submit proof of all staff Training log to LPA Brown at Plan of Correction (POC) due date.

Type A

Section Cited

CCR

87705(f)(2)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. 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 locking the one (1) bottle of cleaning supply in residents shared bathroom making it accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/09/2024
	Plan of Correction
1 2 3 4	Licensee stated to train all staff on CCR 87705(f)(2) and submit proof of all staff training log to LPA Brown at POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/08/2024 12:20 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: HAMNER MANOR	FACILITY NUMBER: 336423397
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87355(e)(3)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not transferring Staff #6 (S6) criminal background clearance to the facility before allowing S6 to work at the facility which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/15/2024
	Plan of Correction
1 2 3 4	Licensee transferred S6 criminal background clearance to the facility during the visit on 03/08/2024. Plan of Correction (POC) cleared.

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 by having Resident #1 (R1), Resident #3 (R3), and Resident #4 (R4)n with half bed rails and no written record from their 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: 03/15/2024
	Plan of Correction
1 2 3 4	Licensee removed R1, R3 and R4 half bed rails during the visit. Plan of Correction (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: 03/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/08/2024 12:20 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: HAMNER MANOR	FACILITY NUMBER: 336423397
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87608(a)(5)(B)

Postural Supports

(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by having Resident #5 (R5) with full bed rail and R5's not on hospice or no written order from R5's physician indicating the need for full bed rail and no exemption filed and approved by CCLD on R5's file which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/15/2024
	Plan of Correction
1 2 3 4	Licensee removed full bed rail during the visit on 03/08/2024. Plan of Correction (POC) cleared.

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: 03/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024

LIC809 (FAS) - (06/04)

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