336427235-10-29-2024-56-AS-MBRN-DAJ54F-20241029193728

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336427235
Report Date: 10/29/2024
Date Signed: 10/29/2024 07:37:48 PM

Document Has Been Signed on 10/29/2024 07:37 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME:	CORONA RESIDENTIAL CARE CENTER LLC		FACILITY NUMBER:	336427235
ADMINISTRATOR/ DIRECTOR:	AHARON STRIKS		FACILITY TYPE:	740
ADDRESS:	1400 CIRCLE CITY DR		TELEPHONE:	(951) 735-0252
CITY:	CORONA	STATE: CA	ZIP CODE:	92879
CAPACITY: 125	TOTAL ENROLLED CHILDREN: 0	CENSUS: 90	DATE:	10/29/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:50 PM
MET WITH:	Assistant Administrator Mary Gonzalez		TIME VISIT/ INSPECTION COMPLETED:	07:45 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 10/29/2024 at 12:50 PM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Brown met with a staff and was granted entry to the facility. Assistant Administrator Mary Gonzalez was informed of the visit and met with LPA Brown. At the time of the visit there were 90 residents present. The facility is a seventy-five bedroom and eighty (80) bathrooms with a kitchen/dining area, living room, beauty shop, laundry room. The facility is a Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of one hundred twenty-five (125) non-ambulatory residents and with an approved hospice waiver for ten (10) and the current census is 90 residents. LPA Brown was accompanied by Assistant Administrator Mary Gonzalez 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 75 degrees Fahrenheit. LPA Brown inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean with a water temperature of 107 degrees Fahrenheit and appliances were operating appropriately. LPA Brown observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors and carbon monoxide detectors were observed. 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, LPA Brown did not observe the CCLD complaint poster. Technical Violation will be issued. During the visit, Assistant Administrator Gonzalez posted the required CCLD poster. LPA Brown tested the call button/pull cord on five (5) residents room and observed the call button/pull cord in good working condition. 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. *Continuation in LIC809C *

Efren Malagon	TELEPHONE: (951) 202-6356
Melody Brown	TELEPHONE: 951-897-2187
	DATE: 10/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024

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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: CORONA RESIDENTIAL CARE CENTER LLC	FACILITY NUMBER: 336427235
	VISIT DATE: 10/29/2024

NARRATIVE

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There is a Medicine Room with the resident’s medications locked. LPA Brown observed complete first aid kit with first aid book maintained at the facility.

During the tour of the facility, LPA Brown observed Resident #5 (R5) and Resident #6 (R6) with half bed rail but no written order from their physician indicating the need for half bed rail for mobility. Deficiency will be issued.

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. However, LPA Brown observed two (2) kitchen staff - Staff #6 (S6) and Staff #7 (S7) with expired food handler certification. Deficiency will be issued.

Care & Supervision: The facility has a certified Administrator present during the visit 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 Brown reviewed five (5) resident files for admission agreements, physician reports, pre-placement appraisals, Centrally Stored Medication List, and Preplacements Needs and Services plans/Care Plan. LPA Brown observed that Resident #3 (R3) does not have a completed Pre-Admission Appraisal. Deficiency will be issued. Also, LPA Brown observed that Resident #1 (R1), Resident #2 (R2) and Resident #5 (R5) do not have the required Preplacement Needs and Services Plan/Care Plan. Deficiency will be issued. Moreover, LPA Brown observed Resident #2 (R2) Physician Report was incomplete because it does not have the required physician signature date. Deficiency will be issued. Furthermore, LPA Brown observed Resident #5 (R5) Admission Agreement was not signed by the Licensee/Administrator/Designee. Deficiency will be issued. LPA Brown reviewed five (5) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test results. LPA Brown observed that files reviewed were complete.

During medication audit, LPA Brown observed that staffs at the facility did not assist Resident #1 (R1) and Resident #4 (R4) with their two (2) medications. Deficiency will be issued.

Per records review, the facility were cited for the same regulations within 12-month period for California Code of Regulation (CCR) 87465(a)(4) and civil penalty will be issued today, 10/28/2024 with the amount of $1,000.00 for third offense within 12-month period. ***Continuation in LIC809C***

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/29/2024 07:37 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: CORONA RESIDENTIAL CARE CENTER LLC	FACILITY NUMBER: 336427235
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(a)(4)

Incidental Medical and Dental Care Services

(4) The licensee shall assist residents with self-administered medications as needed. 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 staffs at the facility are assisting Resident #1 (R1) and Resident #4 (R4) with their two (2) medications per their physician's order which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/30/2024
	Plan of Correction
1 2 3 4	Licensee stated to train all staff on CCR 87465(a)(4) and submit proof of training log to LPA Brown on Plan of Correction (POC) due date.

Type A

Section Cited

CCR

87458(a)

Medical Assessment

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. 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 Resident #2 (R2) Physician Report was complete upon admission to the facility as evidenced of R2 physician report does not have the required physician signature date which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/30/2024
	Plan of Correction
1 2 3 4	Licensee stated to train all staff on CCR 87458(a) and submit training log to LPA Brown on POC due date. Also, Licensee will submit a copy of R2's completed physician report to LPA Brown 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: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/29/2024 07:37 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: CORONA RESIDENTIAL CARE CENTER LLC	FACILITY NUMBER: 336427235
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(15)

General Food Service Requirements

(b) The following food service requirements shall apply: (15) All persons engaged in food preparation and service shall observe personal hygiene and food services sanitation practices which protect the food from contamination. 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 two (2) kitchen staff - Staff #6 (S6) and Staff #7 (S7) have an updated food handler certification which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/08/2024
	Plan of Correction
1 2 3 4	Licensee stated to submit copies of two (2) kitchen staff - S6 and S7 updated food handlers certification to LPA Brown on Plan of Correction (POC) due date

Type B

Section Cited

CCR

87456(a)(2)

Evaluation of Suitability for Admission

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal. 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 Resident #3 (R3) have a completed Pre-Admission Appraisal which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/08/2024
	Plan of Correction
1 2 3 4	Licensee stated to train all staff on CCR 87456(a)(2) and submit a training log to LPA Brown 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: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024

LIC809 (FAS) - (06/04)

Page: 4 of 8

Document Has Been Signed on 10/29/2024 07:37 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: CORONA RESIDENTIAL CARE CENTER LLC	FACILITY NUMBER: 336427235
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87457(c)

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. 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 Resident #1 (R1), Resident #2 (R2) and Resident #5 (R5) have the required Preplacement Needs and Services Plan/Care Plan which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/08/2024
	Plan of Correction
1 2 3 4	Licensee stated to train all staff on CCR 87457(c) and submit training log to LPA Brown on Plan of Correction (POC) due date.

Type B

Section Cited

CCR

87507(c)

Admission Agreements

(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above. 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 Resident #5 (R5) Admission Agreement was signed by the Licensee/Administrator/Designee which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/08/2024
	Plan of Correction
1 2 3 4	Licensee stated to train all staff on CCR 87507(c) and submit training log to LPA Brown 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: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024

LIC809 (FAS) - (06/04)

Page: 5 of 8

Document Has Been Signed on 10/29/2024 07:37 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: CORONA RESIDENTIAL CARE CENTER LLC	FACILITY NUMBER: 336427235
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87608(a)(5)(A)

Postural Supports

(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. 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 allowing Resident #5 (R5) and Resident #6 (R6) to have half bed rail and not ensuring that there's a written order from their physician inidicating the need for half bed rail for mobility which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/08/2024
	Plan of Correction
1 2 3 4	Licensee stated to obtain a written order from R5 and R6 physician indicating the need for half bed rail for mobility and submit copies to LPA Brown on Plan of Correction (POC) due date or remove R5 and R6 half bed rail and submit proof to LPA Brown on POC due date.

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: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024

LIC809 (FAS) - (06/04)

Page: 6 of 8

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: CORONA RESIDENTIAL CARE CENTER LLC	FACILITY NUMBER: 336427235
	VISIT DATE: 10/29/2024

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 26 27 28 29 30 31 32	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, LIC421IM and Appeal Rights were discussed and provided to Assistant Administrator Mary Gonzalez.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024

LIC809 (FAS) - (06/04)

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