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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336423941
Report Date: 09/23/2024
Date Signed: 09/23/2024 03:59:08 PM

Document Has Been Signed on 09/23/2024 03:59 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:NOAH'S RAINBOW ADULT HOMEFACILITY NUMBER:
336423941
ADMINISTRATOR/
DIRECTOR:		RUTH ANGUIANOFACILITY TYPE:
735
ADDRESS:3510 STATE STREETTELEPHONE:
(408) 807-1274
CITY:CORONASTATE: CAZIP CODE:
92881
CAPACITY: 6CENSUS: 6DATE:
09/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Ruth Anguiano, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:10 PM
NARRATIVE
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On 09/23/2024 at 12:30 PM, Licensing Program Analysts (LPAs) Melody Brown and Eldin Serrano conducted an unannounced visit to the facility to conduct the required comprehensive annual inspection to the facility. LPAs Brown and Serrano were greeted by Administrator Ruth Anguiano and gained access at the home. LPAs Brown and Serrano explained the purpose of the visit to Administrator Ruth Anguiano .

The facility has seven (7) bedrooms, four (4) bathrooms, kitchen, dining room, living room, attached garage, and backyard. The facility is vendorized by Inland Regional Center (IRC). The facility are licensed for 6 of which can be non-ambulatory. LPAs Brown and Serrano completed a walkthrough of the facility, review of records, Personal and Incidental (P&I) and medications audit.



Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD), LPAs Brown and Serrano observed six (6) clients during the visit. There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 74 degrees Fahrenheit. LPAs Brown and Serrano inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, chairs, and sufficient lighting. LPAs Brown and Serrano inspected client bathrooms; bathrooms were clean, and appliances were found functional. Water temperatures tested at 106 degrees Fahrenheit. The facility is equipped with operational combined smoke detectors and carbon monoxide detectors, charged fire extinguishers, and first aid kit with first aid book. In addition, LPAs Brown and Serrano observed non-slip mat on client’s bathroom.

Posters such as the personal rights, CCLD complaint poster, and emergency disaster plan were posted in a common area. Client medications were kept in secure cabinets inaccessible to clients. LPAs Brown and Serrano observed night lights at the hallway leading to clients' shared bathrooms. The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility.
*** Continuation in LIC809C ***
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: NOAH'S RAINBOW ADULT HOME
FACILITY NUMBER: 336423941
VISIT DATE: 09/23/2024
NARRATIVE
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Yards/Outside: One shaded patio, one (1) side gate with self-latching handle on the right side of the house that leads into the backyard, attached three (3) car garage observed. Observed swimming pool gate is locked with the required fence. All outdoor pathways were free of obstructions.

Food Service: LPAs Brown and Serrano observed two (2) day(s) supply of perishable food and seven (7) day(s) supply of non-perishables food and snacks. Dishes, cups, and utensils were stored properly.


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

Record Review: LPAs Brown and Serrano reviewed three (3) client files for admission agreements, medical assessments/physician reports, centrally stored medication list, and Individual Program Plan (IPP). LPAs Brown and Serrano observed files reviewed were complete. LPAs Brown and Serrano also reviewed staff and administrator's file for First Aid/CPR certification, emergency intervention (CPI) certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test result. LPAs observed staff 3 (S3) did not complete the required tuberculosis (TB) test and TB test result maintained in S3 file. Deficiency will be issued. Also, LPAs observed staff 4 (S4) did not complete the required emergency intervention (CPI) training. Deficiency will be issued.

LPAs Brown and Serrano audited three (3) clients’ medications. LPAs observed client 1 (C1) one (1) medication was not given per C1's physician direction and client 2 (C2) six (6) medications were not given per C2's physician direction. Deficiency will be issued. LPAs Brown and Serrano audited three (3) client's Personal and Incidental (P&I) and no issues observed.

Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809D, and Appeal Rights were discussed, and copies were provided to Administrator Ruth Anguiano.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/23/2024 03:59 PM - It Cannot Be Edited


Created By: Eldin Serrano On 09/23/2024 at 03:10 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
RIVERSIDE, CA 92507

FACILITY NAME: NOAH'S RAINBOW ADULT HOME
FACILITY NUMBER: 336423941

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above by not ensuring staff 3 (S3) complete the required tuberculosis (TB) test and TB test result maintained in S3 file. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/24/2024
Plan of Correction
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2
3
4
Licensee stated to obtain medical appointment for staff3 (S3) to complete the required TB test and submit proof of the appointment date to LPA Serrano on the plan of correction (POC) due date.
Type A
Section Cited
CCR
80075(b)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that client 1 (C1) one (1) medication was given per C1's physician direction and client 2 (C2) six (6) medications were given per C2's physician direction. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/24/2024
Plan of Correction
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4
LIcensee stated to train all staff who dispenses medications to clients on CCR 80075(b) and submit proof of All Staff training log to LPA Serrano 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:Karen Clemons
LICENSING EVALUATOR NAME:Eldin Serrano
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 09/23/2024 03:59 PM - It Cannot Be Edited


Created By: Eldin Serrano On 09/23/2024 at 03:10 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
RIVERSIDE, CA 92507

FACILITY NAME: NOAH'S RAINBOW ADULT HOME
FACILITY NUMBER: 336423941

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85165(b)
Emergency Intervention Staff Training
(b) Staff who use, participate in, approve or provide visual checks of manual restraint or seclusion, shall have a minimum of sixteen hours of emergency intervention training and be certified for having successfully completed the training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above by not ensuring staff 4 (S4) complete the required emergency intervention (CPI) training which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/24/2024
Plan of Correction
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Licensee stated to submit proof of enrollment/registration for Staff 4 (S4) to complete the required CPI training on plan of correction (POC) due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Karen Clemons
LICENSING EVALUATOR NAME:Eldin Serrano
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2024


LIC809 (FAS) - (06/04)
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