336426511-9-19-2024-56-AS-RHSL-D99V6V-20240919161009

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336426511
Report Date: 09/19/2024
Date Signed: 09/19/2024 04:10:34 PM

Document Has Been Signed on 09/19/2024 04:10 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:	AVISTA SENIOR LIVING MAGNOLIA		FACILITY NUMBER:	336426511
ADMINISTRATOR:	BLASIA LEE-LOLE		FACILITY TYPE:	740
ADDRESS:	737 MAGNOLIA AVE		TELEPHONE:	(951) 737-1600
CITY:	CORONA	STATE: CA	ZIP CODE:	92879
CAPACITY:	180	CENSUS: 106	DATE:	09/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Executive Director, Kellie Smith		TIME COMPLETED:	04:15 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	On 09/19/2024 at 09:00 AM, Licensing Program Analysts (LPAs) Renese Howell-Small, and Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPAs Howell-Small, and Brown met with a staff and was granted entry to the facility. Executive Director (ED) Kellie Smith was informed of the visit and met with LPAs Howell-Small, and Brown. At the time of the visit there were 106 residents present. The facility is a one hundred fifty-seven (157) bedroom, one hundred fifty-seven (157) bathrooms with a kitchen/dining area, living room, theater room, library, laundry room. The facility is a Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of one hundred eighty (180) non-ambulatory residents and with an approved hospice waiver for fifteen (15) and the current census is 106 residents. LPAs Howell-Small and Brown were accompanied by ED Kellie Smith 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 Division (CCLD). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 71 degrees Fahrenheit. LPAs Howell-Small, and Brown inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean with a water temperature of 117 degrees Fahrenheit and appliances were operating appropriately. LPAs Howell-Small and Brown observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors, but no carbon monoxide detectors were observed at the facility. Deficiency will be issued. Fire extinguishers were also observed at the facility. Posters such as personal rights, ombudsman poster, labor laws, and the disaster plan were posted in a common area. However, LPAs Howell-Small and Brown did not observe the CCLD complaint poster. Technical Violation will be issued. During the visit ED Smith posted the required CCLD poster. *Continuation in LIC809C *

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 836-2748
LICENSING EVALUATOR NAME: Renese Howell-Small	TELEPHONE: (951) 248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

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: AVISTA SENIOR LIVING MAGNOLIA	FACILITY NUMBER: 336426511
	VISIT DATE: 09/19/2024

NARRATIVE

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LPA's Howell-Small, and Brown tested the call button on 09/19//24 at 11:30AM in Resident's room# 302 and waited for 10 minutes. LPA's observed that the call button is in disrepair and a staff came and confirmed that the call button is in disrepair and replaced the battery. Deficiency will be issued.

Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. There is a Medicine Room with the resident’s medications locked. LPAs Howell-Small and Brown observed complete first aid kit but no first aid book maintained at the facility. A deficiency will be issued. During the visit Resident Care Director Blasia Lee-Lole downloaded and printed the required First Aid book.

Food Service: More than seven (7) days’ supply of Non-perishable foods and more than two (2) days’ supply of perishable food supply were observed and sufficient for the number of residents in care. All kitchen staff have their updated ServSafe Certification and Food Handlers’ card.

Care & Supervision: The facility has an Executive Director present in the facility with the required hours to effectively manage the facility. The facility has a sufficient number of staff to provide care and supervision to the residents in care.

Record Review: LPA's Howell-Small and Brown reviewed five (5) resident files for admission agreements, updated physician reports, pre-placement appraisals and needs and services plans and the centrally stored medication list. LPA's Howell-Small and Brown observed resident files reviewed were complete. LPA's Howell-Small and Brown reviewed five (5) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test results. LPA's Howell-Small and Brown observed that files reviewed were not complete. LPAs observed no completed Health Screening report for Staff #5 (S5). A deficiency will be issued. Also, LPAs observed Staff #3 (S3) and Staff #5 (S5) did not complete the required TB test. A deficiency will be issued.

LPA's audited five (5) resident's medications and 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), LIC809D, LIC9102 forms and Appeal Rights were discussed and provided to ED Kellie Smith.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 836-2748
LICENSING EVALUATOR NAME: Renese Howell-Small	TELEPHONE: (951) 248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/19/2024 04:10 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: AVISTA SENIOR LIVING MAGNOLIA	FACILITY NUMBER: 336426511
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.311

Regulations

Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that they have the required carbon monoxide detectors at the facility, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/20/2024
	Plan of Correction
1 2 3 4	Licensee obtained carbon monoxide detectors and installed them in the hallways of the facility during the visit. Plan of Correction (POC) cleared.

Type A

Section Cited

CCR

87303(i)(1)(B)

Maintenance and Operation

(i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above by not ensuring that the call button in room #302 was operable, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/20/2024
	Plan of Correction
1 2 3 4	Licensee replaced the battery in the non-operable call button in room #302 during the visit. POC cleared.

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) 836-2748
LICENSING EVALUATOR NAME: Renese Howell-Small	TELEPHONE: (951) 248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/19/2024 04:10 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: AVISTA SENIOR LIVING MAGNOLIA	FACILITY NUMBER: 336426511
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87412(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) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above by not ensuring that Staff #5 (S5) completed the required Health Screening, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/20/2024
	Plan of Correction
1 2 3 4	Licensee stated to submit proof of S5 Health Screening report or medical appointment to complete the required Health Screening report to LPA Howell-Small on Plan of Correction (POC) due date.

Type A

Section Cited

CCR

87412(a)(12)

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: (12) Hazardous health conditions documents as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that Staff #3 (S3) and Staff #5 (S5) completed the required Tuberculosis (TB) test with the required TB test result, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/20/2024
	Plan of Correction
1 2 3 4	Licensee stated to submit the required Tuberculosis (TB) test with the required TB test result or medical appointment to complete the required TB test with TB test result to LPA Howell-Small 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	TELEPHONE: (951) 836-2748
LICENSING EVALUATOR NAME: Renese Howell-Small	TELEPHONE: (951) 248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

LIC809 (FAS) - (06/04)

Page: 3 of 6

Document Has Been Signed on 09/19/2024 04:10 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: AVISTA SENIOR LIVING MAGNOLIA	FACILITY NUMBER: 336426511
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(a)(8)(A)

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following: (A) A current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above by not having the required current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/20/2024
	Plan of Correction
1 2 3 4	Licensee downloaded and printed the required current edition of a first aid manual approved by the American Red Cross during the visit. Plan of Correction (POC) cleared.

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: Karen Clemons	TELEPHONE: (951) 836-2748
LICENSING EVALUATOR NAME: Renese Howell-Small	TELEPHONE: (951) 248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

LIC809 (FAS) - (06/04)

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