361800147-10-14-2024-56-AS-ESEO-DA3222-20241014170001

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361800147
Report Date: 10/14/2024
Date Signed: 10/14/2024 05:00:47 PM

Document Has Been Signed on 10/14/2024 05:00 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	MONTCLAIR ROYALE SENIOR LIVING		FACILITY NUMBER:	361800147
ADMINISTRATOR:	SANTOS, ANNAMARIE		FACILITY TYPE:	740
ADDRESS:	9685 MONTE VISTA AVE		TELEPHONE:	(909) 621-3545
CITY:	MONTCLAIR	STATE: CA	ZIP CODE:	91763
CAPACITY:	236	CENSUS: 133	DATE:	10/14/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Gwendolyne Galvan, Assistant Resident Care Coordinator		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 10/14/2024 at 09:15 AM, Licensing Program Analysts (LPA) Melody Brown and Eldin Serrano made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection LPAs Brown and Serrano met with Assitant Resident Care Coordinator Gwendolyne Galvan and was granted entry to the facility. At the time of the visit there were twenty seven (27) staffs present, and one hundred thirty three (133) residents present. The facility is a eighty four (84) bedrooms, eighty four (84) bathroom facility with a kitchen/dining area, living room/activity room, TV room. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of eighty six (86) ambulatory, one hundred fifty (150) non ambulatory, fifteen (15) hospice care and 15 maybe bedridden resident and the current census is one hundred thirty three (133) residents. LPAs Brown and Serrano was accompanied by ARCC 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 Division (CCLD). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 74 degrees Fahrenheit. LPAs 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. LPAs observed sufficient furniture and lighting throughout the facility. LPAs measured and observed the water temperatures in the bathroom for room #104 to be at 114.4 degrees Fahrenheit, Room# 246 to be at 115.8 degrees Fahrenheit, Room #311 to be at 115.1 degrees Fahrenheit . The facility is equipped with operating smoke detectors and did not observe carbon monoxide alarms. LPAs observed that the facilty do not have the required carbon monoxide detector installed on each floor of the facility. Deficiency will be issued. *Continuation in LIC809C *

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Eldin Serrano	TELEPHONE: 951-248-0351
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2024

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: MONTCLAIR ROYALE SENIOR LIVING	FACILITY NUMBER: 361800147
	VISIT DATE: 10/14/2024

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***Continuation in LIC809C ***

Fire extinguishers were observed on every floor at the facility. Posters such as personal rights, the CCLD complaint poster, ombudsman poster, labor laws, and the disaster plan were posted in a common area. LPAs obeserved resident #1 (R1) and resident #2 (R2) with half bedrail but per interview and documents review there is no written order from their physician indicating the need for half bed rail for mobility, Defiiciency will be issued. LPAs observed floor surface in resident bathroom and the floor bathroom for residents and staff were not clean. Deficiency will be issued.

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. LPAs 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 two (2) days’ supply of perishable food supply were observed and sufficient for the number of residents in care.

Care & Supervision: The facility has no Administrator present in the facility with appropriate and enough hours to appropriately manage the facility. Based on interview and LPAs observation facility administrator was not present at the facility for three (3) consecutive weeks and not at the facility during working hours. Deficiency will be issued.

Record Review: LPAs reviewed five (5) resident files for admission agreements, updated physician reports, pre-placement appraisals and needs and services plans. LPAS observed resident #2 (R2) does not have the required pre-placement appraisal. Deficiency will be issued. LPAs observed Resident #2 (R2) #3 (R3) and #4 (R4), does not have the signed and dated admission agreement. Deficiency will be issued. LPAS observed no completed needs and services for resident #5 (R5) and facility representative did not sign the completed needs and services plan for resident #2 (R2) and resident #4 (R4). deficiency will be issued. LPAs reviewed five (5) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) Test result. LPAs observed staff #4 (S4) does not have the required tuberculosis (TB) test and TB test result. Deficiency will be issued. LPAs observed staff #3 (S3) does not have the required updated ServSafe certification and staff #4 (S4) does not have the required update food handlers card. Deficiency will be issued.

Medications/Medication Administration Record (MAR) were audited for 5 residents and no issues observed.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Eldin Serrano	TELEPHONE: 951-248-0351
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/14/2024 05:00 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MONTCLAIR ROYALE SENIOR LIVING	FACILITY NUMBER: 361800147
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/14/2024

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 the required carbon monoxide detector installed on each floor of the facility, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/15/2024
	Plan of Correction
1 2 3 4	Licensee stated to submit proof of installed carbon monoxide detector on each floor of the facility to LPA Serrano on plan of correction (POC) due date.

Type A

Section Cited

CCR

87412(a)(12)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) Hazardous health conditions documents as specified in Section 87411, Personnel Requirements - General. 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 ensuring that staff #4 (S4) has the required tuberculosis (TB) test and TB test result, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/15/2024
	Plan of Correction
1 2 3 4	Licensee stated to submit medical appointment for Staff #4 to complete the required TB test with TB test result to LPA Serrano on POC due 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: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Eldin Serrano	TELEPHONE: 951-248-0351
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/14/2024 05:00 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MONTCLAIR ROYALE SENIOR LIVING	FACILITY NUMBER: 361800147
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)(1)

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. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. 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 ensuring that floor surface in resident bathroom and the floor bathroom for residents and staff were clean which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/22/2024
	Plan of Correction
1 2 3 4	Licensee stated to submit a copy of housekeeping schedule specific to cleaning resident bathrooms to LPA Serrano on plan of correction (POC) due date.

Type B

Section Cited

HSC

1569.618(a)

Other Provisions

(a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility. 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 ensuring that the facility administrator was present at the facility for three (3) consecutive weeks and not at the facility during normal working hours which poses a potential health, safety or personal rights ris k to persons in care.
	POC Due Date: 10/22/2024
	Plan of Correction
1 2 3 4	Licenseee stated to submit proof of updated staff schedule showing the administrator working at the facility during normal working hours to LPA Serrano on POC due 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: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Eldin Serrano	TELEPHONE: 951-248-0351
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2024

LIC809 (FAS) - (06/04)

Page: 4 of 10

Document Has Been Signed on 10/14/2024 05:00 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MONTCLAIR ROYALE SENIOR LIVING	FACILITY NUMBER: 361800147
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(15)

General Food Service Requirements

(b) The following food service requirements shall apply: (15) All persons engaged in food preparation and service shall observe personal hygiene and food services sanitation practices which protect the food from contamination. 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 ensuring that staff #3 (S3) does not have the required updated ServSafe certification and staff #4 (S4) has an updated food handler card, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/22/2024
	Plan of Correction
1 2 3 4	Licensee stated to submit proof of S3 updated ServSafe certification and S4 food handlers card to LPA Serrano on plan of correction (POC) due date.

Type B

Section Cited

CCR

87456(a)(2)

Evaluation of Suitability for Admission

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal. 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 ensuring that resident #2 (R2) has the required pre-placement appraisal which poses a potential health, safety or personal , risk to persons in care.
	POC Due Date: 10/22/2024
	Plan of Correction
1 2 3 4	Licensee stated to submit signed statement of understanding on CCR 87456(a)(2) to LPA Serrano on POC due 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: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Eldin Serrano	TELEPHONE: 951-248-0351
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2024

LIC809 (FAS) - (06/04)

Page: 5 of 10

Document Has Been Signed on 10/14/2024 05:00 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MONTCLAIR ROYALE SENIOR LIVING	FACILITY NUMBER: 361800147
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87507(c)

Admission Agreements

(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above. 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 ensuring that facility representative signed Resident #2 (R2) resident #3 (R3) and resident #4 (R4) admission agreement which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/22/2024
	Plan of Correction
1 2 3 4	Licensee stated to sign R2, R3, R4 admission agreement and submit signed statement of understanding on CCR 87507(c) to LPA Serrano on plan of correction (POC) due date.

Type B

Section Cited

HSC

1569.695(e)(2)

Other Provisions

(e) A facility shall have all of the following information readily available to facility staff during an emergency: (2) An appraisal of resident needs and services plan for each resident. 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 ensuring that resident #5 (R5) has the required needs and services plan and facility representative sign the completed needs and services plan for resident #2 (R2) and resident #4 (R4), which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/22/2024
	Plan of Correction
1 2 3 4	Licensee stated to submit signed statement of understanding on HSC 1569.695(e)(2) to LPA Serrano on POC due 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: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Eldin Serrano	TELEPHONE: 951-248-0351
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2024

LIC809 (FAS) - (06/04)

Page: 6 of 10

Document Has Been Signed on 10/14/2024 05:00 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MONTCLAIR ROYALE SENIOR LIVING	FACILITY NUMBER: 361800147
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87608(a)(5)(A)

Postural Supports

(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. 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 ensuring that resident #1 (R1) and resident #2 (R2) have half bedrail with written order from their physician indicating the need for half bed rail for mobility, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/22/2024
	Plan of Correction
1 2 3 4	Licensee stated to submit copies of R1 and R2 written order from their physician indicating the need for half bedrail for mobility to LPA Serrano on plan of correction (POC) due date. Also, Licensee that if they are not able to obtain the physician order to remove the half bedrails and submit proof to LPA Serrano on POC due date.

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: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Eldin Serrano	TELEPHONE: 951-248-0351
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2024

LIC809 (FAS) - (06/04)

Page: 7 of 10

Document Has Been Signed on 10/14/2024 05:00 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MONTCLAIR ROYALE SENIOR LIVING	FACILITY NUMBER: 361800147
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(c)(5)

87705 CAre of Persons with Dementia (c) Licensse who accept and retain residents with dementia shall be responsible for ensuring the following:(5) Each resident with dementia shall have an annual medical assessment as specified in section 87458, medical assessment... 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 ensuring that resident #3 (R3) has the required annual medical assessment as R3s medical asessment date is 08/12/2022 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/15/2024
	Plan of Correction
1 2 3 4	Licensee stated to obtain a medical appointment for R3 to complete the required annual medical assessment and submit proof to LPA Serrano on the plan of correction (POC) due date.

Type A

Section Cited

CCR

87705(l)(7)

87705 Care of Person with Dementia. (l) The following iniatial and conitnuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (7) The licensee shall not accept or retain residents determined by a physician to have a primary diagnosis of a mental disorder unrelated to dementia. 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 accepting resident #2 (R2) in memory care and per documents review R2 does not have a diagnosis of dementia but with a primary diagnosis of a mental disorder unrelated to dementia which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/15/2024
	Plan of Correction
1 2 3 4	Licensee stated to remonve R2 in memory care and transfer R2 to assisted living and submit proof to LPA Serrano on POC due 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: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Eldin Serrano	TELEPHONE: 951-248-0351
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2024

LIC809 (FAS) - (06/04)

Page: 9 of 10

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: MONTCLAIR ROYALE SENIOR LIVING	FACILITY NUMBER: 361800147
	VISIT DATE: 10/14/2024

NARRATIVE

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However, LPAs observed resident #3 (R3) does not have the required annual medical assessment as required for resident with dementia as R3s medical assessment date is 08/12/2022. Deficiency will be issued.

Also, LPAs observed that resident #2 (R2) is in memory care and per documents review R2 does not have a diagnosis of dementia but with a primary diagnosis of a mental disorder unrelated to dementia. Deficiency will be issued.

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 forms, and Appeal Rights were discussed and provided to Assistant Resident Care Coordinator Gwendolyne Galvan.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Eldin Serrano	TELEPHONE: 951-248-0351
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2024

LIC809 (FAS) - (06/04)

Page: 10 of 10