336426688-3-7-2024-56-AS-MMAE-D362BF-20240307161503

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336426688
Report Date: 03/07/2024
Date Signed: 03/07/2024 04:15:34 PM

Document Has Been Signed on 03/07/2024 04:15 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:	HEARTLAND MANOR		FACILITY NUMBER:	336426688
ADMINISTRATOR:	AHMED QASIM		FACILITY TYPE:	740
ADDRESS:	178 W. PENDLETON ROAD		TELEPHONE:	(951) 849-7750
CITY:	BANNING	STATE: CA	ZIP CODE:	92220
CAPACITY:	22	CENSUS: 16	DATE:	03/07/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Amirr Younes - Manager		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	Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Amirr Younes, Manager, and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) with a license capacity of (22), a current census of (16) residents in care and a hospice waiver for (6). 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. Indoor and Outdoor area is sufficient for resident activities; however, the facility accepts and/or retains residents with Dementia and a section of the facility fence was observed torn providing unsafe direct street access. Deficiency cited. Ten (10) resident’s showers, toilets, and hand washing areas were fully operational. The hot water temperature in residents' bathrooms measured 107 degrees F; However, the bathroom in bedroom #10 had a missing door handle. Deficiency cited. Ten (10) Resident’s bedrooms had required beds, linen, chairs and sufficient lighting. The facility has operating carbon monoxide alarms, signal system, telephone service and is maintained at a comfortable temperature. The facility has sufficient linen, towels, and personal hygiene items for residents. The facility has posted in a common area, facility license, Community Care Licensing complaint poster, Ombudsman poster, Personal Rights, disaster evacuation plan, and activities. Care & Supervision: Facility has 24-hour, 7 days a week care staff.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: HEARTLAND MANOR	FACILITY NUMBER: 336426688
	VISIT DATE: 03/07/2024

NARRATIVE

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

Record Review: LPA record review of the Administrator's file, (4) staff files and (5) resident files reveals the following: Staff #1 (S1), Staff#2 (S2), staff #3 (S3), staff #4 (S4) did not have record of required 20 hours of annual job training. Deficiency cited. S2 did not have record of medication management training on file. Deficiency cited. Resident #1 (R1) did not have record of tuberculosis results on file. Deficiency cited. The facility did not maintain record of quarterly emergency drill conducted with staff on file. Deficiency cited.

Medical Related Services: Resident’s medications are labeled and centrally stored in a locked cabinet. The facility has a complete first aid kit with manual.

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

An exit interview was conducted where the Licensing reports and a plan of correction was reviewed with Manager Younes. Copies with Appeal Rights were provided to Manager Younes 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: 03/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

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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: HEARTLAND MANOR	FACILITY NUMBER: 336426688
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observations, the licensee did not comply with the section cited above by the bathroom door in bedroom #10 is missing the door handle, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/15/2024
	Plan of Correction
1 2 3 4	The Licensee/Administrator shall submit to the Licensing Agency proof of door handle repair by POC due date.

Section Cited

Personnel Records


	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) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/05/2024 03:51 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 04/05/2024 03:49 PM

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: HEARTLAND MANOR	FACILITY NUMBER: 336426688
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. 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 not maintaining record of required hours of annual training on file for S1, S2, S3, and S4; which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/04/2024
	Plan of Correction
1 2 3 4	The Licensee/Administrator shall submit to the Licensing Agency proof of required staff training by POC due date.

Section Cited

Other Provisions


	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) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/07/2024 04:15 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: HEARTLAND MANOR	FACILITY NUMBER: 336426688
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.69(a)(4)(F)

Other Provisions

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (4) The training shall cover all of the following areas: (F) A description of procedures for providing assistance with the self-administration of medications in and out of the facility, and information on the medication documentation system used in the facility. 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 not maintaining record of Staff #2 (S2) medication management training on file; which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/04/2024
	Plan of Correction
1 2 3 4	The Licensee/Administrator shall submit to the Licensing Agency documentation of Staff#2 (S2) medication management training by POC due date.

Section Cited

Other Provisions


	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) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/07/2024 04:15 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: HEARTLAND MANOR	FACILITY NUMBER: 336426688
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(b)(1)

Medical Assessment

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. 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 not maintaining record of resident #1 (R1's) tuberculosis results on file; which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/04/2024
	Plan of Correction
1 2 3 4	The Licensee/Administrator shall submit to the Licensing Agency documentation of R1's tuberculosis results by POC due date.

Type B

Section Cited

HSC

1569.885(d)

Admission Agreements

Admission Agreements 1569.885(d) In addition to any other notice a licensee is required by law to provide to residents, a written notice, including the current telephone number, internet website address, and email address for the local long-term care ombudsman and the internet website address for the Community Care Licensing Division of the State Department of Social Services shall be included in, or as an attachment to, all admission agreements. 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 not maintaining information on the above in resident R1, R2, R3, and R4's Admissions Agreement or as an attachment to the agreement; which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/04/2024
	Plan of Correction
1 2 3 4	The Licensee/Administrator shall submit to the Licensing Agency proof of required contact information is placed in resident's file 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: 03/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/07/2024 04:15 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: HEARTLAND MANOR	FACILITY NUMBER: 336426688
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(c)(h)

Admission Agreements

Care of Persons with Dementia 87705 (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (h)Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observations, the licensee did not comply with the section cited above. The facility accepts and/or retains residents with Dementia and a section of the facility fence was observed torn providing unsafe direct street access; which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/15/2024
	Plan of Correction
1 2 3 4	The Licensee/Administrator shall submit to the Licensing Agency proof of repaired fence by POC due date.

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 not maintaining on file documentation of a quarterly conducted disaster drill training; which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/04/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator shall provide to the Licensing Agency proof of disaster drill training conducted with staff 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: 03/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

LIC809 (FAS) - (06/04)

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