336423957-4-9-2024-56-AS-RGAR-D46TY4-20240409150808

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336423957
Report Date: 04/09/2024
Date Signed: 04/09/2024 03:08:14 PM

Document Has Been Signed on 04/09/2024 03:08 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:	ADORABLE HOME V		FACILITY NUMBER:	336423957
ADMINISTRATOR:	ROBERT C. CANTORIA		FACILITY TYPE:	740
ADDRESS:	7925 SADDLETREE COURT		TELEPHONE:	(951) 496-3238
CITY:	CORONA	STATE: CA	ZIP CODE:	92880
CAPACITY:	6	CENSUS: 4	DATE:	04/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:35 PM
MET WITH:	Robert C. Cantoria- Administrator		TIME COMPLETED:	03:20 PM

NARRATIVE

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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 Caregiver Lizeth Alonzo Garcia and was granted entry to the facility. During today’s visit, Administrator Robert C. Cantoria was phoned and arrived at the facility during the visit.

The facility is a Residential Care Facility for the Elderly (RCFE) licensed for a capacity of six (6) non-ambulatory clients. The facility is defined as level 4i home vendorized by Inland Regional Center (IRC). The current census is five (5) clients. 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 is maintained at a comfortable temperature. LPA inspected client 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 bathrooms to be at 112.2 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. The postings such as the facility license, personal rights, labor laws, the CCL complaint poster, and the disaster plan were posted in a common area. The cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. There was a designated storage space for client files and staff files. The medications are kept inside a kitchen cabinet inaccessible to the clients in care. The non-perishable and perishable food supply is sufficient for the clients in care.

LPA reviewed five (5) client files for admission agreements, updated physician reports, and needs and services plans. LPA inspected the client’s medications and the client’s medication records. LPA did not observe any medication discrepancies. LPA reviewed six (6) staff files for First Aid/CPR certifications, criminal record clearances, trainings, and health screenings.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024

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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Document Has Been Signed on 04/09/2024 03:08 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: ADORABLE HOME V	FACILITY NUMBER: 336423957
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)

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: 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 allowing S1 to work at the facility since 2018 without a criminal record clearance which poses an immediate health, safety, or personal rights risk to persons in care.
	POC Due Date: 04/10/2024
	Plan of Correction
1 2 3 4	The licensee has agreed to read regulation 87355 entirely and send LPA a statement of understanding that the regulation was read and understood. The licensee has agreed to not allow S1 work at the facility until S1 has a criminal record clearance. POC is due by 4/10/2024.

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: 04/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/09/2024 03:08 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: ADORABLE HOME V	FACILITY NUMBER: 336423957
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. 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 allowing S2 to work at the facility without CPR/first aid training which poses a potential health, safety, or personal rights risk to persons in care.
	POC Due Date: 04/10/2024
	Plan of Correction
1 2 3 4	The licensee has agreed to read health and safety code 1569.618 entirely and send LPA a statement of understanding that the health and safety code was read and understood. The licensee has agreed to have S2 complete CPR/First aid training and not allow S2 to work alone with the clients until CPR/First aid training is completed. POC is due by 4/10/2024.

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: 04/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024

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: ADORABLE HOME V	FACILITY NUMBER: 336423957
	VISIT DATE: 04/09/2024

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During document review, LPA found that Staff S1 has been working at the facility since 2018 without obtaining a criminal record clearance. The facility will be issued a type A deficiency for allowing S1 to work at the facility without obtaining a criminal record clearance. The facility will also be issued a $500-dollar civil penalty.

During document review, LPA found that Staff S2 does not have CPR/first aid training. Staff S2’s CPR/First aid training expired on 1/16/2023. S2 was working alone in the facility when LPA arrived at the facility. The facility will be issued a type B deficiency for allowing S2 to work alone with the clients without CPR/First aid training.

Based on the observations made during today’s visit, two (2) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations, along with a $500-dollar civil penalty.

An exit interview was conducted, and this report (LIC809), LIC809D forms, LIC811, LIC421BG, and the appeal rights were discussed and provided to Administrator Robert C. Cantoria.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024

LIC809 (FAS) - (06/04)

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