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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800007
Report Date: 01/04/2023
Date Signed: 01/04/2023 11:18:00 AM


Document Has Been Signed on 01/04/2023 11:18 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:RYAN'S HOME CAREFACILITY NUMBER:
361800007
ADMINISTRATOR:ROJAS, FRANKLINFACILITY TYPE:
740
ADDRESS:1682 COULSTON STREETTELEPHONE:
(909) 894-4168
CITY:LOMA LINDASTATE: CAZIP CODE:
92354
CAPACITY:6CENSUS: 6DATE:
01/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Staff MemberTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst, Amber Coleman (LPA) arrived at the Ryan's Home Care Facility unannounced to conduct an Annual Inspection with a focus on Infection Control. LPA introduced self and stated the purpose of the visit. LPA was greeted by Staff Member, Lisa Rojas, (S1) and was invited inside facility ad asked to sign in. Upon entry, LPA signed in and observed the facility's COVID station. This station included hand sanitizer, disinfectant wipes, glozes and masks offered to anyone entering facility. S1 stated there are currently 6 residents in care and no one is suspected for tested positive for COVID in the last 2 weeks.

During today's visit, LPAs toured the facility and made observations pertaining to the facility's infection control measures. Appropriate signage for infection control was observed throughout the facility's hallways and walls. Each bathroom included a sufficient supply of hand hygiene and paper supplies. The LPA observed extra supply of Personal Protective Equipment (PPE) that included surgical masks, N-95 masks, face shields, gloves, gowns, glasses, etc. kept secure in garage. The facility has a COVID-19 mitigation plan in place, which outlines testing requirements, isolating/quarantining positive COVID-19 cases, proper cleaning/sanitizing/disinfecting and monitoring of individuals for COVID-19 like symptoms. This was also reviewed during visit. The facility is aware that it is mandatory that Community Care Licensing (CCL) is contacted if anyone tests positive for COVID-19. The facility overall was observed to be clean, orderly and in comfortable temperature.

Fire and Carbon Monoxide Alarms were tested and found to be in proper working condition. Fire extinguishers were fully charged; however last inspected 3/14/2018. LPA reviewed six resident charts. Of six resident charts, LPA observed missing emergency contact information was missing for 4 residents.

Based on the observations made during today’s visit, deficiencies and Technical Violations are were cited per Title 22, Division 6, of the California Code or Regulations. An exit interview to review this report was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:
DATE: 01/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


Document Has Been Signed on 01/04/2023 11:18 AM - 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: RYAN'S HOME CARE
FACILITY NUMBER: 361800007

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
87203
Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. Fire extinguishers checked were charged, except for the extinguisher just outside the door to the court yard. It needs to be recharged.
Deficient Practice Statement
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Based on observation made on 1/4/2032 the licensee did not comply with the section cited above in that fire extinguishers checked were charged, however last inspection was 3/14/2023. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/18/2023
Plan of Correction
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Licensee agrees to have fire extiguishers inspected by fire department or make purchase of new fire extingusihers
Type B
Section Cited
HSC
87506(8)

Resident Records:
Names, address, and telephone numbers of the resident’s representative, as defined in Section 87101(r), to be notified in case of accident, death, or other emergency.
This requirement is not met as evidenced by: LPA observing missing information on resident records.
Deficient Practice Statement
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Based on observation on 1/4/23, the licensee did not comply with the section cited above in [4] out of [6] [resident charts] missing emergency contact information which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/18/2023
Plan of Correction
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Licensee agrees to complete missing information in identified resident charts and submit proof of correction by date listed above.
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: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:
DATE: 01/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 01/04/2023 11:18 AM - 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: RYAN'S HOME CARE
FACILITY NUMBER: 361800007

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
873039a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by: LPA observation of backyard platform on left side of the facility. Cracked and broken platform. Also, wiring used to reenforce neighboring fense for inclement weather.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in by not reporting damaged neighboring gate and flooring. Furthermore maintaining the facility in good repair which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/18/2023
Plan of Correction
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Licensee plans to have repairman fix the neighboring gate and repair flooring on flooring outside of facility.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:
DATE: 01/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4