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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336423880
Report Date: 07/20/2023
Date Signed: 07/20/2023 02:57:51 PM


Document Has Been Signed on 07/20/2023 02:57 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:VISTA COVE AT CORONAFACILITY NUMBER:
336423880
ADMINISTRATOR:COURTNEY BARRETOFACILITY TYPE:
740
ADDRESS:2600 SOUTH MAIN STREETTELEPHONE:
(951) 736-4780
CITY:CORONASTATE: CAZIP CODE:
92882
CAPACITY:49CENSUS: 17DATE:
07/20/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Courtney Barreto TIME COMPLETED:
03:10 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Mary Rico and Ryan Gardner and Licensing Program Managers(LPMs) Karen Clemons and Nedra Brown conducted an unannounced case management visit regarding the facilities fire clearance status with Corona Fire Department.

During today visit, LPA Rico and LPA Gardner toured the facility with Corona Fire Department. The following items were not in compliances: fire rated doors were promptly open; doors should be remained closed. Doors do not have a seal label. No three feet clearance from all electrical panel, toxins were stored in the electrical panel. No gas appliances, no deadbolts, open ceilings, bedroom doors do not lash on themselves, fire alarm not dated, riser room locked, smoke detectors in room 19 not plugged, and heating devices, such as a stove in room 14. A full detailed report will be sent by the Corona Fire Department.

The licensee has agreed to hire a 24hour fire watch employee to work closely with the Corona Fire Department to ensure the safety of the residents in care. The staff will be present until the facility is in compliance with Corona Fire Department. The licensee has agreed to send a daily fire watch log to LPA.

The licensee has agreed to send state licensing an updated LIC200, Application For A Community Facility Or Residential, and a corporate/facility organizational chart.

During facility tour, LPAs discovered the facility is providing care for four (4) bedridden resident which is not approved per the facilities license.

In addition, the Administrator was not present at the facility when LPAs arrived. LPAs asked staff for documentation and were informed to wait until the Administrator returned. The facility should have a designated substitute to assist state licensing during visits.

The licensee was informed that they may be called in for an informal meeting at the State Licensing Regional Office.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary RicoTELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2023
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 07/20/2023 02:57 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: VISTA COVE AT CORONA
FACILITY NUMBER: 336423880

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/21/2023
Section Cited
CCR
87202(a)(2)

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87202. Fire Clearance(a)All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.(2)Bedridden persons.
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The licensee has agreed to read regulation 87202 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to find new placement for the four (4) bedridden resident. The licensee has agreed to send LPA a plan of new placement
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Based on observation, interview and document review, the licensee did not comply with the section cited above evidenced by providing care to four (4) bedridden resident which poses an immediate health, safety, or personal rights risk to persons in care.
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by POC due date 7/21/2023. The licensee has agreed to send LPA proof once the four (4) bedridden resident moves out of the facility.
Type A
07/21/2023
Section Cited
CCR87202(a)

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87202. Fire Clearance(a)All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.
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The licensee has agreed to read regulation 87202 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to send State Licensing their plans to correct fire violations.
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Based on observation, interview and document review, the licensee did not comply with the section cited above evidenced by operating the facility without an approved fire clearance which poses an immediate health, safety, or personal rights risk to persons in care.
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Including any state contactors statements detailing when the corrections will be completed.
POC due date 7/21/2023.
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 MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary RicoTELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 07/20/2023 02:57 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: VISTA COVE AT CORONA
FACILITY NUMBER: 336423880

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/24/2023
Section Cited
CCR
87405(a)

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87405.Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation.

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The licensee has agreed to read regulation 87405 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to designate an administrator substitute in the facility when administrator is not present.
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Based on observation, interview and document review, the licensee did not comply with the section cited above evidenced by not having a designated administrator substitute in the facility when administrator is not present.
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 Licensee has agreed to send LPA an updated LIC500 indicated who the will be designated administrator substitute. POC due date 7/24/2023.

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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 MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary RicoTELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


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: VISTA COVE AT CORONA
FACILITY NUMBER: 336423880
VISIT DATE: 07/20/2023
NARRATIVE
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Based on observations today, a civil penalty in the amount of $1000.00 dollars will be issued for violation of the facilities fire clearance. The facility will be issued two (2) type A deficiencies and one (1) type B deficiency per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809) was discussed and provided to Administrator Courtney Barreto, along with a copy of LIC809D, LIC421IM, and the appeal rights.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary RicoTELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4