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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800061
Report Date: 09/13/2024
Date Signed: 09/16/2024 07:59:14 AM

Document Has Been Signed on 09/16/2024 07:59 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:HELPING HEARTS EUCLIDFACILITY NUMBER:
361800061
ADMINISTRATOR/
DIRECTOR:		SMITH, MELLISAFACILITY TYPE:
772
ADDRESS:747 NORTH EUCLID AVETELEPHONE:
(909) 983-6123
CITY:ONTARIOSTATE: CAZIP CODE:
91762
CAPACITY: 10CENSUS: 10DATE:
09/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Valerie Daniels, Program DirectorTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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On 09/13/2024 at 12:00 PM, Licensing Program Analysts (LPAs) Magda Malcore and Eldin Serrano conducted an unannounced visit to the facility to conduct the required comprehensive annual inspection to the facility. LPAs Malcore and Serrano were greeted by Program Director Valerie Daniels and gained access at the home. LPAs Malcore and Serrano explained the purpose of the visit to Program Director Daniels .

The facility has five (5) bedrooms, three (3) bathrooms, kitchen, dining rooms, living rooms, and courtyard. The facility are licensed for 10 of which can be non-ambulatory. LPAs Malcore and Serrano completed a walkthrough of the facility, review of records, Personal and Incidental (P&I) and medications audit.



Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD), LPAs Malcore and Serrano observed five (5) clients during the visit. There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 76 degrees Fahrenheit. LPAs Malcore and Serrano inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, chairs, and sufficient lighting. LPAs Malcore and Serrano inspected client bathrooms; bathrooms were clean, and appliances were found functional. LPAs observed that the water temperature in bathroom near bedroom 5 is 149 degress fahrenheit, the bathroom near bedroom 3 is 127 degrees fahrenheit and the bathroom near bedroom 2 is 141 degress fahrenheit. Deficiency will be issued. The facility is equipped with operational combined smoke detectors and carbon monoxide detectors, charged fire extinguishers, and first aid kit with first aid book.

Posters such as the personal rights, CCLD complaint poster, and emergency disaster plan were posted in a common area. Client medications were kept in secure cabinets inaccessible to clients. LPAs Malcore and Serrano observed night lights at the hallway leading to clients' shared bathrooms. The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility.
*** Continuation in LIC809C ***
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: HELPING HEARTS EUCLID
FACILITY NUMBER: 361800061
VISIT DATE: 09/13/2024
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Yards/Outside: Courtyard and at back of the house is a parking space observed. All outdoor pathways were free of obstructions.

Food Service: LPAs Malcore and Serrano observed two (2) day(s) supply of perishable food and seven (7) day(s) supply of non-perishables food and snacks. Dishes, cups, and utensils were stored properly.


Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPAs Malcore and Serrano reviewed five (5) client files for admission agreements, medical assessments/physician reports, and Individual Program Plan (IPP). LPAs Malcore and Serrano observed files reviewed were complete. LPAs Malcore and Serrano also reviewed staff and program director's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test result.

LPAs Malcore and Serrano audited five (5) clients’ medications and no issues were observed. LPAs Malcore and Serrano audited five (5) client's Personal and Incidental (P&I) and no issues observed.

Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809D, and Appeal Rights were discussed, and copies were provided to Program Director Valerie Daniels.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/16/2024 07:59 AM - It Cannot Be Edited


Created By: Eldin Serrano On 09/13/2024 at 02:07 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: HELPING HEARTS EUCLID
FACILITY NUMBER: 361800061

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
81088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review,, the licensee did not comply with the section cited above by not ensuring that the water was delivered no more than the max temperature of 120 degrees fahrenheit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/14/2024
Plan of Correction
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Program Director Valerie Daniels will contact the facility maintenance manager to adjust the water heater and they will provide a copy of invoice within the plan of correction (POC) due date.
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:Karen Clemons
LICENSING EVALUATOR NAME:Eldin Serrano
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2024


LIC809 (FAS) - (06/04)
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