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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336427235
Report Date: 04/15/2024
Date Signed: 04/15/2024 01:29:15 PM


Document Has Been Signed on 04/15/2024 01:29 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:CORONA RESIDENTIAL CARE CENTER LLCFACILITY NUMBER:
336427235
ADMINISTRATOR:AHARON STRIKSFACILITY TYPE:
740
ADDRESS:1400 CIRCLE CITY DRTELEPHONE:
(951) 735-0252
CITY:CORONASTATE: CAZIP CODE:
92879
CAPACITY:125CENSUS: 87DATE:
04/15/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Maria "Mary" Gonzalez- Administrator AssistantTIME COMPLETED:
01:40 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 follow up case management visit on a self-reported incident regarding Resident R1 that occurred at the facility on 12/29/2023. LPA met with Administrator Assistant Maria “Mary” Gonzalez and was granted entry to the facility.

LPA conducted an initial visit to the facility on 1/10/2024 to investigate the incident that occurred on 12/29/2023. During the investigation, LPA found through interviews with the staff and document review of R1’s MARs record that R1 was not given their medication from 12/28/2023 around 1PM to 12/29/2023 around 2 PM. The staff made thirteen (13) attempts to contact R1 to provide medication. These contacts included knocking on R1’s door, waiting outside R1’s door, and yelling R1’s name through the door. During these attempts, there was no attempt to open R1’s bedroom door until around thirteen (13) hours after the first contact attempt with R1 on 12/28/2023. The facility failed to ensure that R1 was assisted and provided with their medication during this time frame.

Based on the investigation, one (1) deficiency was cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809), LIC811, and LIC809D were discussed and provided to Administrator Assistant Maria “Mary” Gonzalez, along with a copy of the appeal rights.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 04/15/2024 01:29 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: CORONA RESIDENTIAL CARE CENTER LLC
FACILITY NUMBER: 336427235

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/16/2024
Section Cited
CCR
87465(a)(4)

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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: (4) The licensee shall assist residents with self-administered medications as needed.
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The licensee has agreed to read regulation 87465 entirely and send LPA a statement of understanding that the regulation was read and understood. The licensee has agreed to conduct a medication training with the staff and send LPA proof of attendance by the POC due date. POC is due by 4/16/2024.
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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 the staff not providing medication assistance to R1 which poses an immediate health, safety, or personal rights risk to persons in care.
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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 MalagonTELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2024
LIC809 (FAS) - (06/04)
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