360911233-12-12-2023-56-AS-ABUO-CYG2U5-20231212164146

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 360911233
Report Date: 12/12/2023
Date Signed: 12/12/2023 04:41:56 PM

Document Has Been Signed on 12/12/2023 04:41 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:	LA POSADA II		FACILITY NUMBER:	360911233
ADMINISTRATOR:	HERNANDEZ, ORFA RUTH		FACILITY TYPE:	740
ADDRESS:	3875 NORTH BELLE STREET		TELEPHONE:	(909) 881-1344
CITY:	SAN BERNARDINO	STATE: CA	ZIP CODE:	92404
CAPACITY:	11	CENSUS: 6	DATE:	12/12/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:37 PM
MET WITH:	Orfa Ruth Hernandez Chernovsky		TIME COMPLETED:	04:44 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	Licensing Program Analyst (LPA) Anna Bueno made an unannounced visit to conduct a required annual inspection. LPA was greeted by licensee Ruth Chernovsky who was informed of the purpose of the visit. LPA and licensee toured the interior and exterior of the facility. Physical Plant and Safety of Environment/Operational Requirements: LPA observed a fenced pool area with a locked gate. LPAs observed the facility to be clean and in good repair. The home is maintained at a comfortable temperature for the residents. Lighting is sufficient for safety and comfort. Water temperature measured to be comfortable for residents. Laundry facilities and locked cabinets were present for storing laundry soap and other chemicals. Fire extinguishers are charged and last inspected on 02/03/23. All outdoor and indoor passageways are free of obstruction. A locked area is provided for medications and sharp objects. There is a working telephone at this location. The LIC 610E, emergency disaster plan is maintained. The facility has a current written definitive plan of operation. The facility is maintained in conformity with the regulations adopted by the state fire marshal. Personnel Records/Training/and Staffing-. LPA reviewed employee records for fingerprint clearance, personnel/job application, health screening and TB test results, criminal record statement, employee rights, training verification, and current administrator certification. LPA did not observe current first aid certification, certifications expired in 2021. This poses a potential health and safety concern for clients in care. Resident Records/Incident Reports/Personal Rights/Residents with Special Needs/Incidental Medical and Dental: LPA reviewed resident records and found that they contained records including, admission agreement, medical assessment and TB test results, consent forms, identification and emergency information, appraisal needs and service plans, safeguard for personal property/valuables, and personal rights notification. The facility is meeting documentation requirements. Resident Rights are posted in the facility and a copy is signed on file. During the visit, facility staff completed the centrally stored medication. LPA did not observe necessary records for PRN medication and administration. This poses a potential health and safety risk to clients in care.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna Bueno	TELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

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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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: LA POSADA II	FACILITY NUMBER: 360911233
	VISIT DATE: 12/12/2023

NARRATIVE

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Food Service: LPA Bueno was present during dinner time. LPA observed the meal is adequate to meet the nutritional needs of the residents, including a service of vegetables, protein, and scalloped potatoes. Food prep areas are clean and organized. Food supply meets the requirement of one week supply of nonperishable and 2-day supply of perishables food on hand.

LPA Bueno made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. The facility has not exceeded its capacity limitation and the structure remains unchanged according to the approved floor plan. Smoke detectors were tested by Licensee Chirnovsky while LPA Bueno tested the bedroom hallways carbon monoxide detectors. All units were found to be operational.

Based on the information received during this visit today, the following deficiencies are being cited per Title 22, Division 6 of The California Code of Regulations. Refer to LIC 809D for cited deficiencies. This report and LIC 809D were reviewed with and a copy provided to the facility representative. Appeal Rights were also provided at the time of the exit interview.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna Bueno	TELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/12/2023 04:41 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: LA POSADA II	FACILITY NUMBER: 360911233
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review conducted by LPA Bueno and interview with licensee Ruth Chirnovsky, the licensee did not comply with the section cited above in three staff files reviewed were without a current CPR certification which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/29/2023
	Plan of Correction
1 2 3 4	Licensee shall provide proof of current CPR/First Aid training for all staff providing care and supervision. Proof shall be submitted to the Department no later than end of POC date.

Type B

Section Cited

CCR

87465(d)(1)

Incidental Medical and Dental Care Services

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (1) Facility staff shall contact the resident's physician prior to each dose, describe the resident's symptoms, and receive direction to assist the resident in self-administration of that dose of medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review conducted by LPA Bueno and interview with licensee Ruth Chirnovsky, the licensee did not comply with the section cited above as licensee could not provide contact records for resident physician for R1's PRN/as needed medication which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/29/2023
	Plan of Correction
1 2 3 4	Licensee shall provide proof of PRN medication and PRN administration training for all staff administering medication. Licensee shall be submit proof of training or list of PRN medication administration to the Department no later than end of POC date.

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 Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna Bueno	TELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/12/2023 04:41 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: LA POSADA II	FACILITY NUMBER: 360911233
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(b)

Other Provisions

(b) A facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review conducted by LPA Bueno and interview with licensee Ruth Chirnovsky, the licensee did not comply with the section cited above as licensee could not provide current emergency disaster training for all staff which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/29/2023
	Plan of Correction
1 2 3 4	Licensee shall provide proof of current in-house disaster training for all staff providing care and supervision. Proof shall be submitted to the Department no later than end of POC date.

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review conducted by LPA Bueno and interview with licensee Ruth Chirnovsky, the licensee did not comply with the section cited above as licensee could not provide current emergency disaster training for all staff which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/29/2023
	Plan of Correction
1 2 3 4	Licensee shall provide proof of current in-house disaster training for all staff providing care and supervision. Proof shall be submitted to the Department no later than end of POC date.

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 Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna Bueno	TELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

LIC809 (FAS) - (06/04)

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