336427426-11-7-2023-56-AS-RGAR-CXCUFQ-20231107143306

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336427426
Report Date: 11/07/2023
Date Signed: 11/07/2023 02:37:08 PM

Document Has Been Signed on 11/07/2023 02:37 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	INSPIRATIONS HOME CARE VII		FACILITY NUMBER:	336427426
ADMINISTRATOR:	GARCIA, DOMINIC		FACILITY TYPE:	740
ADDRESS:	1507 CHESTNUT CIR		TELEPHONE:	(951) 870-5676
CITY:	CORONA	STATE: CA	ZIP CODE:	92881
CAPACITY:	6	CENSUS: 6	DATE:	11/07/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:08 PM
MET WITH:	Noelia Garcia-Administrator		TIME COMPLETED:	02:47 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 a required comprehensive annual inspection LPA met with Administrator Noelia Garcia and was granted entry to the facility. At the time of the visit, there were three (3) staff present and six (6) residents present.

The facility is a four (4) bedroom, two and half (2.5) bathroom home with a kitchen, a dining area, a living room area, and an attached garage. The facility is a Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) non-ambulatory residents, one (1) of the six (6) residents may be bedridden. The current census is six (6) residents. LPA was accompanied by Administrator 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 interior and exterior passageways. The facility is maintained at a comfortable temperature. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperature in the bathroom to be at 116.4 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Postings such as the facility license, personal rights, the CCL complaint poster, labor laws, and the disaster plan were posted in a common area. 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. Medications are kept inside the medication cabinet in the kitchen inaccessible to residents. Overall, the facility is clean and in good repair.

Food Service: Non-perishable and perishable food supply is sufficient for the residents in care.

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

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

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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Document Has Been Signed on 11/07/2023 02:37 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: INSPIRATIONS HOME CARE VII	FACILITY NUMBER: 336427426
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

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 interview, document review, and observation, the licensee did not comply with the section cited above evidenced by R1 not having an updated medical assessment. R1's most recent medical assessment is dated 3/23/2022 which poses a potential health, safety, or personal rights risk to persons in care.
	POC Due Date: 11/24/2023
	Plan of Correction
1 2 3 4	The licensee has agreed to read regulation 87458 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to have Resident R1’s doctor complete an updated medical assessment and send proof to LPA. POC is due by 11/24/2023.

Type B

Section Cited

HSC

1569.695(e)(2)

Other Provisions

(e) A facility shall have all of the following information readily available to facility staff during an emergency: (2) An appraisal of resident needs and services plan for each resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, document review, and observation, the licensee did not comply with the section cited above evidenced by not having needs and services plans for three (3) out of three (3) residents files checked which poses a potential health, safety, or personal rights risk to persons in care.
	POC Due Date: 11/13/2023
	Plan of Correction
1 2 3 4	The licensee has agreed to read health and safety code 1569.695 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed that moving forward all resident’s will have a resident needs and services plan in their file. The licensee has agreed to complete a needs and services plan for all the residents. POC is due by 11/13/2023.

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) 248-8222
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

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

FACILITY NAME: INSPIRATIONS HOME CARE VII	FACILITY NUMBER: 336427426
	VISIT DATE: 11/07/2023

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Record Review: LPA reviewed three (3) residents files for admission agreements, updated physician reports, and needs and services plans. LPA discovered that one (1) out of three (3) residents did not have an updated physician’s report/medical assessment. LPA discovered that three (3) out of the three (3) residents did not have needs and services plans in their files. The facility will be issued a type B deficiency for not having needs and services plans for the residents. The facility will be issued a type B deficiency for not having an updated physician’s report/medical assessment. LPA reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. Medications/MARs records were audited and appeared to be dispensed and logged appropriately.

Based on the observations made during today’s visit, two (2) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809) and LIC809D were discussed and provided to Administrator Noelia Garcia, along with a copy of the appeal rights.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

LIC809 (FAS) - (06/04)

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