336426057-11-14-2024-56-AS-RHEZ-DAZW3Y-20241114155640

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336426057
Report Date: 11/14/2024
Date Signed: 11/14/2024 03:57:14 PM

Document Has Been Signed on 11/14/2024 03:57 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	EASTVALE SENIOR HOME CARE		FACILITY NUMBER:	336426057
ADMINISTRATOR/ DIRECTOR:	ADELAIDA BADILLO		FACILITY TYPE:	740
ADDRESS:	14394 HEALY LAKE STREET		TELEPHONE:	(951) 356-5270
CITY:	EASTVALE	STATE: CA	ZIP CODE:	92880
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	11/14/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:50 AM
MET WITH:	Administrator Laarni Dizon		TIME VISIT/ INSPECTION COMPLETED:	04:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Raquel Hernandez made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Administrator Bene Molinitas and was granted entry to the facility. Licensed capacity is (6) current census (6). LPA was accompanied by Administrator Laarni Dizon 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 (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. LPA observed cleaning supplies and knives unlocked accessible to clients in care. Deficiency will be issued. Additionally, LPA observed Client #1 (C1) medications located underneath the sink unlocked accessible to residents in care. Deficiency LPA observed facility is not in substantial compliance with requirements regarding hospice care residents as there are three (3) hospice care residents. Facility is only granted two (2). Deficiency will be issued.

Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Facility has a variety of food available for residents. Dishes, cups, and utensils were also stored properly.

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

Record Review: LPA reviewed (4) resident files for admission agreements, updated physician reports, pre-placement appraisals and needs and services plans. LPA reviewed (4) resident medications

**Continuation on LIC809C**

Efren Malagon	TELEPHONE: (951) 202-6356
Raquel Hernandez	TELEPHONE: 951-248-0336
	DATE: 11/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024

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

FACILITY NAME: EASTVALE SENIOR HOME CARE	FACILITY NUMBER: 336426057
	VISIT DATE: 11/14/2024

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LPA observed for Client #1 (C1), Client #2 (C2), Client #3 (C3) and Client #4 (C4) staff are not properly documenting PRN medication/administration. No date, time, resident's response was taken. Deficiency will be issued. LPA also reviewed (3) staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings. No issues were observed.

Based on the observations made during today’s visit, deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809) and (LIC809-D) was discussed and provided to Administrator Laarni Dizon

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Raquel Hernandez	TELEPHONE: 951-248-0336
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/14/2024 03:57 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: EASTVALE SENIOR HOME CARE	FACILITY NUMBER: 336426057
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Maintenance and Operation

(f) Solid waste shall be stored and disposed of as follows: (2) Syringes and needles are disposed of in accordance with the California Code of Regulations, Title 8, Section 5193 concerning bloodborne pathogens. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above by having syringes and needles located underneath kitchen cabinet and not disposed in accordance with California Code of Regulations, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/15/2024
	Plan of Correction
1 2 3 4	Licensee stated to submit staff training on how to properly dispose of syringes and needles to LPA Hernandez by Plan of Correction (POC) due date.

Section Cited

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above by not enusring all cleaning solutions and disinfectants are kept locked inacessible to clients in care, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/15/2024
	Plan of Correction
1 2 3 4	Licensee stated to submit staff training on how to properly store chemicals and cleaning solutions to LPA Hernandez 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.

Efren Malagon	TELEPHONE: (951) 202-6356
Raquel Hernandez	TELEPHONE: 951-248-0336
	DATE: 11/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/14/2024 03:57 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: EASTVALE SENIOR HOME CARE	FACILITY NUMBER: 336426057
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above by not ensuring Client #1 (C1) medication is locked and stored properly, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/15/2024
	Plan of Correction
1 2 3 4	Licensee stated to submit photo documentation of all medication locked and stored properly by Plan of Correction (POC) due date.

Section Cited

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: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review the licensee did not comply with the section cited above by not ensuring Client #1 (C1), Client #2 (C2), Client #3 (C3) and Client #4 (C4) PRN medication is documented properly within regulation, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/15/2024
	Plan of Correction
1 2 3 4	Licensee stated to submit staff training on how to properly document PRN medications to LPA Hernandez 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.

Efren Malagon	TELEPHONE: (951) 202-6356
Raquel Hernandez	TELEPHONE: 951-248-0336
	DATE: 11/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/14/2024 03:57 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: EASTVALE SENIOR HOME CARE	FACILITY NUMBER: 336426057
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Hospice Care for Terminally Ill Residents

(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility, when all of the following conditions are met: (2) The licensee remains in substantial compliance with the requirements of this section, with the provisions of the Residential Care Facilities for the Elderly Act (Health and Safety Code Section 1569 et seq.), all other requirements of Chapter 8 of Title 22 of the California Code of Regulations governing Residential Care Facilities for the Elderly, and with all terms and conditions of the waiver. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review the licensee did not comply with the section cited above by not ensuring the facility is in substantial compliance with requirements regarding hospice care residents as there are three (3) hospice care residents, facility is only granted two (2), which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/15/2024
	Plan of Correction
1 2 3 4	Licensee stated to submit hospice waiver increase form to LPA Hernandez by Plan of Correction (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.

Efren Malagon	TELEPHONE: (951) 202-6356
Raquel Hernandez	TELEPHONE: 951-248-0336
	DATE: 11/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024

LIC809 (FAS) - (06/04)

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