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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360902944
Report Date: 04/18/2023
Date Signed: 04/18/2023 04:12:54 PM


Document Has Been Signed on 04/18/2023 04:12 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:INLAND CHRISTIAN HOME, INCFACILITY NUMBER:
360902944
ADMINISTRATOR:MARY WOLFFFACILITY TYPE:
741
ADDRESS:1950 SOUTH MOUNTAIN AVENUETELEPHONE:
(909) 983-0084
CITY:ONTARIOSTATE: CAZIP CODE:
91762
CAPACITY:297CENSUS: 175DATE:
04/18/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:03 PM
MET WITH:Memory Care Director Denise PerezTIME COMPLETED:
04:20 PM
NARRATIVE
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On 04/18/2023 at 12:03 PM, Licensing Program Analyst (LPA) Melody Brown met with Memory Care Director Denise Perez to initiate Case Management Visit. The investigation consisted of observation, interviews and a review of pertinent documentation.

During the facility visit last 04/18/2023 at 12:03 PM, LPA Brown reviewed documents and observed that Staff #3 (S3) have a current criminal background clearance but S3 is not currently associated to the facility. Staff interviews and records review indicated S3 had been working at the facility for five (5) years now. LPA Brown informed Memory Care Director Perez that deficiency will be issued as this pose potential health, safety and personal rights risks to residents in care.

Civil Penalty was assessed with the amount of $500.00 during the Facility Visit for failure to transfer S3 Criminal Background Clearance to the facility.

In addition, interviews with staffs and residents indicated that Certified Nursing Assistants (CNA)/Medical Technicians (MedTech) are performing residents' blood glucose testing. Memory Care Director Perez confirmed to LPA Brown that the CNAs and MedTechs at the facility are performing residents' blood glucose testing during the facility visit 04/18/2023. LPA Brown explained to Memory Care Director Perez that blood glucose testing must be administered by an appropriately skilled professional and CNAs and MedTechs must stop from performing blood glucose testing to residents today, 04/18/2023 and Memory Care Director Perez expressed understanding. LPA Brown indicated that deficiency will be issued as this pose immediate health, safety and personal rights risks to residents in care,

An exit interview was conducted where this report (LIC809), LIC809D, LIC421BG and Appeal Rights were discussed and provided to Memory Care Director Denise Perez.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2023
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 04/18/2023 04:12 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: INLAND CHRISTIAN HOME, INC
FACILITY NUMBER: 360902944

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/19/2023
Section Cited

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87628 Diabetes (a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional. This requirement is not met as evidenced by:
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Licensee stated to not allow CNAs/MedTechs staff to perform blood glucose testing today 04/18/2023 and will submit proof of appropriately skilled professional performing blood glucose check to LPA Brown by POC due date.
Licensee will submit signed Statement of Uunderstanding on CCR 87628(a) to LPA brown by POC due date.
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Based on interview and records review, the Licensee did not comply with the section cited above by allowing CNAs/MedTechs to perform blood glucose testing to residents which pose immediate health, safety and personal rights risks to residents in care.
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Type B
04/25/2023
Section Cited

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87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working... (2)Request a transfer of a criminal record clearance... This requirement is not met as evidenced by:
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Licensee stated to transfer S3's criminal backround clearance to the facility and associate S3 to the facility and submit proof to LPA Brown by POC due date.
Licensee stated to submit signed Statement of Understanding on CCR 87355(e)(2) to LPA Brown by POC due date.
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Based on observation, interviews and records review, the Licensee did not comply with the section cited above by not trasferring S3's crimminal backround clearance to the facility before allowing S3 to work at the facility which pose potential safety risks to residents 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) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2023
LIC809 (FAS) - (06/04)
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