336425524-3-18-2024-56-AS-MMAE-D3GRE5-20240318125657

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336425524
Report Date: 03/18/2024
Date Signed: 03/18/2024 12:57:19 PM

Document Has Been Signed on 03/18/2024 12:57 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:	EMORY TERRACE		FACILITY NUMBER:	336425524
ADMINISTRATOR:	RAYMOND CHU		FACILITY TYPE:	740
ADDRESS:	34 EMORY AVENUE		TELEPHONE:	(951) 402-3697
CITY:	BEAUMONT	STATE: CA	ZIP CODE:	92223
CAPACITY:	6	CENSUS: 6	DATE:	03/18/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Elizabeth Zarate		TIME COMPLETED:	01:00 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	Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Elizabeth Zarate, Assisting Administrator, and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) with a license capacity of (6), a current census of (6) residents, and a hospice waiver for (2). LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: Physical Plant/Environment: Indoor and outdoor passageways are free of obstruction. The facility has no swimming pools or similar bodies of water. The facility's backyard area is sufficient for resident activities and is enclosed with a self-latching gate. Resident’s showers, toilets, and hand washing areas were operating in a safe and sanitary condition. Resident bathrooms were equipped with grab rails and non-skid flooring or non-skid mats. The hot water temperature in residents' bathrooms measured 111 degrees F. Resident’s bedrooms had beds, chairs, night stands, sufficient lighting and maintained at a comfortable temperature. The facility had operating carbon monoxide alarms, laundry equipment, and telephone service. The facility had sufficient linen, towels, and personal hygiene items for residents. The facility had sufficient activity supplies for residents in care. The facility's fire place is kept covered. Disinfectants and cleaning solutions were kept locked and inaccessible to residents in care. The facility has posted in a common area, Ombudsman poster, facility license, and evacuation exit plan sketch; However, the facility did not have posted, a list of emergency telephone numbers and a Residential Care Facility complaint poster. Deficiency cited. Care & Supervision: Facility has 24-hour, 7 days a week direct care staff.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024

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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: EMORY TERRACE	FACILITY NUMBER: 336425524
	VISIT DATE: 03/18/2024

NARRATIVE

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Food Service: Facility kitchen and dining areas are maintained clean. The facility has sufficient non-perishable and perishable food supply for residents in care. Sharps were kept locked and inaccessible to residents in care.

Record Review: Review of (5) staff files reveal: staff#1 (1), staff#2 (S2), staff#3 (3), staff#4 (S4), staff#5 (S5) did not have documentation of in-service annual Dementia training on file. S1 and S5 did not have documentation of CPR/First Aid training on file. Review of (5) resident files reveal: resident #1 (R1) did have a pre-admission appraisal on file. The facility did not maintain record of a current quarterly drill conducted with staff. The facility’s last fire/earthquake drill on file was conducted on 12/14/2022. Deficiency cited.

Medical Related Services: Resident’s medications are labeled and centrally stored in a locked room. The facility had sufficient first aid supplies. A first aid manual is kept at the facility.

Based on observations and record review, deficiencies are being cited per Title 22, of The California Code of Regulations and Health and Safety Codes.

This report was reviewed with the Assisting Administrator and a copy with Appeal Rights was provided to the Assisting Administrator at the conclusion of the visit.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024

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: EMORY TERRACE	FACILITY NUMBER: 336425524
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Other Provisions


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Type B

Section Cited

CCR

87411(c)(1)

Personnel Requirements - General

(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 LPA record review, the licensee did not comply with the section cited above by Staff #1 (S1) and Staff #5 (S5) did not have documentation of CPR/First Aid training on file; which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/17/2024
	Plan of Correction
1 2 3 4	The Licensee shall submit to the Licensing Agency documentation of CPR/First Aid training by 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	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/18/2024 12:57 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: EMORY TERRACE	FACILITY NUMBER: 336425524
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.626(a)(2)

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: (2) Eight hours of in-service training per year on the subject of serving residents with dementia. This training shall be developed in consultation with individuals or organizations with specific expertise in dementia care or by an outside source with expertise in dementia care. In formulating and providing this training, reference may be made to written materials and literature on dementia and the care and treatment of persons with dementia. This training requirement may be satisfied in one day or over a period of time. This training requirement may be provided at the facility or offsite and may include a combination of observation and practical application. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA record review, the licensee did not comply with the section cited above by the Licensee did not maintain on file documentation of annual Dementia training for S1, S2, S3, S4, and S5; which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/17/2024
	Plan of Correction
1 2 3 4	The Licensee shall submit to the Licensing Agency documentation of in-service staff Dementia training by 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	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/18/2024 12:57 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: EMORY TERRACE	FACILITY NUMBER: 336425524
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87468(c)(2)(A)

Personal Rights of Residents

(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation the licensee did not comply with the section cited above by not posting in the hallway a Residential Care Facility Complaint poster; which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/17/2024
	Plan of Correction
1 2 3 4	The Licensee shall submit to the Licensing Agency proof of Complaint information posted in the main hallway by 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	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/18/2024 12:57 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: EMORY TERRACE	FACILITY NUMBER: 336425524
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Pre-Admission Appraisal


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Type B

Section Cited

CCR

87457(c)(1)

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. (1) The appraisal shall include, at a minimum, an evaluation of the prospective resident's functional capabilities, mental condition and an evaluation of social factors as specified in Sections 87459, Functional Capabilities and 87462, Social Factors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA record review, the licensee did not comply with the section cited above by resident #1 (R1) did have a pre-admission appraisal; which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/17/2024
	Plan of Correction
1 2 3 4	The Licensee shall submit to the Licensing Agency documentation of resident appraisal by 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	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024

LIC809 (FAS) - (06/04)

Page: 6 of 10

Document Has Been Signed on 03/18/2024 12:57 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: EMORY TERRACE	FACILITY NUMBER: 336425524
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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 LPA record review, the licensee did not comply with the section cited above by which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/17/2024
	Plan of Correction
1 2 3 4	The Licensee shall submit to the Licensing Agency documentation of current quarterly emergency drill by POC due date.

Type B

Section Cited

CCR

87212(c)

Emergency Disaster Plan

(c) Emergency exiting plans and telephone numbers shall be posted. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above by not posting emergency telephone numbers at the facility; which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/17/2024
	Plan of Correction
1 2 3 4	The Licensee shall submit to the Licensing Agency proof of posted emergency telephone numbers by 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	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024

LIC809 (FAS) - (06/04)

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