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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360902944
Report Date: 04/28/2023
Date Signed: 04/28/2023 01:59:16 PM


Document Has Been Signed on 04/28/2023 01:59 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: DATE:
04/28/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:29 AM
MET WITH:Administrator Mary WolffTIME COMPLETED:
02:00 PM
NARRATIVE
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On this day, Licensing Program Analyst (LPA) Anna Bueno conducted a subsequent unannounced visit to this facility to continue the investigation and deliver findings of complaint number 18-AS-20220228123141.

During the investigation, LPA discovered that the facility has not submitted any incident report to Community Care Licensing (CCL). LPA further found that there were two resident deaths that were not reported to CCL. This poses a potential health, safety, and personal rights risk to residents in care.

Refer to LIC809-D for deficiency issued. An exit interview was conducted with and a copy of this report, LIC809-D, and appeal rights were provided to Memory Care Director Denise Perez.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023
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 04/28/2023 01:59 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: 04/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/05/2023
Section Cited

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(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events...
(A) Death of any resident from any cause regardless of where the death occurred...
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Facility shall submit death report for two unit resident deaths that occurred in 2023. Facility shall review RCFE reporting guidelines as indicated in CCR 77211.
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This requirement was not met as evidenced by:

LPA reviewed special incident reports and found that the facility has not reported any incidents in 2023, specifiaclly two residents deaths in 2023.
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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: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023
LIC809 (FAS) - (06/04)
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