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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360902944
Report Date: 08/04/2023
Date Signed: 08/04/2023 12:26:05 PM


Document Has Been Signed on 08/04/2023 12:26 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: 153DATE:
08/04/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Memory Care Director Denise PerezTIME COMPLETED:
12:30 PM
NARRATIVE
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On 08/04/2023 at 09:45 AM, 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 on 08/04/2023 at 10:15 AM, LPA Brown reviewed documents and observed that Staff #4 (S4) and Staff#5 (S5) have a current criminal background clearance but S4 and S5 are not currently associated to the facility. Staff interviews and records review indicated S4 had been working at the facility since 06/07/2023 and S5 had been working at the facility since 02/19/2019. 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.

LPA Brown reviewed compliance history and observed that the facility was issued the same deficiency for a staff working at facility and the facility failed to transfer staffs’ criminal background clearance on 04/18/2023. Civil Penalty was assessed for repeat violation on Criminal Background Clearance within a 12-month period with the amount of $3,000.00 per individual and will continue to be assessed of $100.00 per day per citation until corrected during the facility visit today due to the facility allowed S4 and S5 to work and failed to transfer S4 and S5 Criminal Background Clearance to the facility.

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: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2023
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 08/04/2023 12:26 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: 08/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/14/2023
Section Cited
CCR
87355(e)(2)

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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 S4 and S5 criminal background clearance to the facility and associate S4 and S5 to the facility and submit proof to LPA Brown by POC due date.
Licensee stated to submit proof of Staff In-Sevice Log 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 transferring S4 and S5 criminal background clearance to the facility before allowing S4 and S5 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: 08/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2023
LIC809 (FAS) - (06/04)
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