360902944-1-8-2024-56-AS-MBRN-CZB3FH-20240108171245

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 360902944
Report Date: 01/08/2024
Date Signed: 01/08/2024 05:13:04 PM

Document Has Been Signed on 01/08/2024 05:13 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, INC		FACILITY NUMBER:	360902944
ADMINISTRATOR:	MARY WOLFF		FACILITY TYPE:	741
ADDRESS:	1950 SOUTH MOUNTAIN AVENUE		TELEPHONE:	(909) 983-0084
CITY:	ONTARIO	STATE: CA	ZIP CODE:	91762
CAPACITY:	297	CENSUS: 138	DATE:	01/08/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Memory Care and Assisted Living Director Denise Perez		TIME COMPLETED:	05:15 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 01/08/2024 at 09:05 AM, 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. Executive Director David Steinstra and Executive Director Mary Wolfe arrived at the facility during the visit. At the time of the visit there were one hundred thirty-eight (138) residents present. The facility is a residential care for the elderly (RCFE) Continuing Care Retirement Community (CCRC). The facility is licensed for a capacity of two hundred ninety-seven (297) of which eighty-two (82) Ambulatory and two hundred fifteen (215) non-Ambulatory and five (5) Hospice Waiver residents. Also, the facility’s approved for delayed egress and approved for secured perimeter. LPA Brown was accompanied by Memory Care and Assisted Living Director Denise Perez 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 indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA Brown 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 Brown observed sufficient furniture and lighting throughout the facility. LPA Brown measured and observed the water temperatures in the bathroom to be at 112 degrees F. The facility is equipped with operating smoke detectors however, LPA Brown observed no carbon monoxide alarms throughout the facility. Deficiency will be issued. The facility purchased the required carbon monoxide alarms during the visit on 01/08/2024 and installed it throughout the hallway of the facility. Moreover, fire extinguishers were also observed at the facility. Posters such as personal rights, the CCL complaint poster, labor laws, and the disaster plan were posted in a common area. *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: 01/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2024

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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Document Has Been Signed on 01/08/2024 05:13 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: 01/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.311

Regulations

Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above by not having a carbon monoxide detector in the facility that meet the standards in Chapter 8 of Part 2 of Division 12 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/09/2024
	Plan of Correction
1 2 3 4	Licensee purchased carbon monoxide detectors that meet the standards in Chapter 8 of Part 2 of Division 12 during the visit on 01/08/2024. Plan of Correction (POC) cleared.

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: 01/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/08/2024 05:13 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: 01/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(d)

(d) The Licensee shall maintain documentation that an adminitrator has met the certification requirements specified in Setion 87406, Administrator Certification Requirements or the recertification requirements in section 87407, Administrator Recertification Requirements. 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 processing the Administrator certification renewal on time as per documents review, LPA Brown observed S1 Administrator Certification expired and no renewal packet was submitted for processing iwhich poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/19/2024
	Plan of Correction
1 2 3 4	Licensee mailed Administrator renewal packet during the visit on 01/08/2024. Plan of Correction (POC) cleared.

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: 01/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2024

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: INLAND CHRISTIAN HOME, INC	FACILITY NUMBER: 360902944
	VISIT DATE: 01/08/2024

NARRATIVE

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

Food Service: More than seven (7) days’ supply of Non-perishable foods and more than three (3) days’ supply of perishable food supply were observed and sufficient for the number of residents in care. All kitchen staff have their updated ServSafe Cerification and food handlers card.

Care & Supervision: The facility has an Executive Director David Steinstra present in the facility with appropriate and enough hours to appropriately manage the facility. The facility has sufficient number of staff to provide care and supervision to the residents in care.

Record Review: LPA Brown reviewed fourteen (14) resident files for admission agreements, updated physician reports, pre-placement appraisals and needs and services plans. LPA Brown observed that Resident #2(R2) and Resident #14 (R14) don't have their Admission Agreement in their facility file. Technical Violation Issued. Memory Care and Assisted Living Director Perez reprinted R2 and R14 Admission Agreement and kept it in their facility file during the visit on o1/08/2024. LPA Brown reviewed five (5) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA Brown observed files reviewed were complete except for Staff #1 Administrator Certification expired and no renewal packet submitted for processing. During the visit on 01/08/2024. Deficiency will be issued. S1 mailed the renewal packet for processing. Medications/Medication Administration Record (MAR) were audited during the visit on 01/08/2024, and LPA Brown observed no issue.

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 forms, and Appeal Rights were discussed and provided to Memory Care and Assisted Living Director Denise Perez.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 01/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2024

LIC809 (FAS) - (06/04)

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