<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800187
Report Date: 11/06/2023
Date Signed: 11/06/2023 11:51:45 AM


Document Has Been Signed on 11/06/2023 11:51 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:ROSE VALLEY REDLANDSFACILITY NUMBER:
361800187
ADMINISTRATOR:GLENN BERNALFACILITY TYPE:
740
ADDRESS:153 S DEARBORN STTELEPHONE:
(909) 389-7586
CITY:REDLANDSSTATE: CAZIP CODE:
92374
CAPACITY:6CENSUS: 6DATE:
11/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Iren CreightonTIME COMPLETED:
11:45 AM
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) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Iren Creighton, Facility Representative, and discussed the purpose of the visit.

The facility is a Residential Care Facility for the Elderly (RCFE). License capacity of (6) with a current census of (6). LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:
Physical Plant: Indoor passageways are free of obstruction. The facility has sufficient lighting and is maintained at a comfortable temperature. Resident’s bathrooms are equipped with grab rails and operating in safe and sanitary conditions. The hot water temperature in residents' bathrooms measured 112 degrees F. Resident’s bedrooms have sufficient lighting and bedroom furniture is in good repair. Facility has operating carbon monoxide alarms and telephone service. Facility fireplace is adequately screened. The facility has sufficient linen, towels, and personal hygiene items for residents. The facility has posted in a common area, Community Care Licensing complaint poster, Ombudsman poster, disaster evacuation plan and emergency telephone numbers.
Yards/Outside: Outdoor passageways are free of obstruction. The facility has no bodies of water accessible to residents in care. The facility is enclosed with self-latching gates. Outdoor shaded area is sufficient for resident activities.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:
DATE: 11/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2023
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 9


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: ROSE VALLEY REDLANDS
FACILITY NUMBER: 361800187
VISIT DATE: 11/06/2023
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
26
27
28
29
30
31
32
Food Service: Facility has sufficient non-perishable and perishable food supply for residents in care. The refrigerator and freezer are operating in a healthful manner. Disinfectants and other cleaning solutions were kept locked and stored away from food areas.
Care & Supervision: Facility has 24-hour/7 days a week care staff. Staff working have criminal record clearances or exemptions through the Department.
Record Review: LPA reviewed (3) resident files and (3) staff files. Licensee did not maintain verification of staff #1 (S1) complete health screening results. Resident (R1) and resident #2 (R2) preplacement appraisals were observed incomplete. Licensee did not maintain proof of R1's complete health screening results. LPA observed facility's last emergency drill was conducted in July 2019. Facility did not maintain verification of liability insurance on file for licensing review.
Medical Related Services: All medication is centrally stored, administered as prescribed and kept in a locked closet, inaccessible to residents in care.

Deficiencies were cited during today's visit and a plan of correction was discussed with facility representative, Iren Creighton.

An exit interview was conducted and copies of the licensing reports with appeal rights were provided to the facility representative at the conclusion of the visit.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023
LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 11/06/2023 11:51 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: ROSE VALLEY REDLANDS
FACILITY NUMBER: 361800187

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks.  Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.  A report shall be made of each screening, signed by the examining physician.  The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents.  A signed statement shall be obtained from each volunteer affirming that he/she is in good health.  Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA file review, the licensee did not comply with the section cited above by not maintaining verification of staff #1 complete health screening results, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2023
Plan of Correction
1
2
3
4
Licensee/Administrator shall submit to the licensing agency proof of staff #1 TB results by 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 ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:
DATE: 11/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2023
LIC809 (FAS) - (06/04)
Page: 3 of 9


Document Has Been Signed on 11/06/2023 11:51 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: ROSE VALLEY REDLANDS
FACILITY NUMBER: 361800187

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA file review, the licensee did not comply with the section cited above by not maintaining verification of liability insurance on file for Licensing review, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2023
Plan of Correction
1
2
3
4
Licensee/Administrator shall submit to the licensing agency proof of liability insurance by POC due date.
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA file review, the licensee did not comply with the section cited above by Resident #1 (R1) and resident #2 (R2) preplacement appraisals were observed incomplete, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2023
Plan of Correction
1
2
3
4
Licensee/Administrator shall submit to the Licensing Agency proof of correction by 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 ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:
DATE: 11/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2023
LIC809 (FAS) - (06/04)
Page: 4 of 9


Document Has Been Signed on 11/06/2023 11:51 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: ROSE VALLEY REDLANDS
FACILITY NUMBER: 361800187

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(b)(1)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA file review, the licensee did not comply with the section cited above by Resident #1 (R1) did not have verfication of complete health screening results, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2023
Plan of Correction
1
2
3
4
Licensing/Administrator shall submit to the licensing agency proof of TB results by POC due 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 LPA file review and observations, the licensee did not comply with the section cited above by last emergency drill was conducted in July 2019, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2023
Plan of Correction
1
2
3
4
Licensee/Administrator shall conduct a emergency drill with staff and submit proof of correction to the licensing agency by 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 ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:
DATE: 11/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2023
LIC809 (FAS) - (06/04)
Page: 5 of 9