361800228-12-6-2023-56-AS-MMAE-CY9S78-20231206123706

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361800228
Report Date: 12/06/2023
Date Signed: 12/06/2023 12:37:27 PM

Document Has Been Signed on 12/06/2023 12:37 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	ABSOLUTE QUALITY CARE HOME		FACILITY NUMBER:	361800228
ADMINISTRATOR:	MARCHANY, RACHEL		FACILITY TYPE:	740
ADDRESS:	10731 COLOMA ST.		TELEPHONE:	(909) 253-1571
CITY:	LOMA LINDA	STATE: CA	ZIP CODE:	92354
CAPACITY:	6	CENSUS: 5	DATE:	12/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Rachel Marchany, Administrator		TIME COMPLETED:	12:45 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) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with, Rachel Marchany, Administrator and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) with a license capacity of (6) with a current census of (5) residents in care. The facility has a hospice waiver for (2). LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: Physical Plant: Indoor and outdoor passageways are free of obstruction. Outdoor shaded area is sufficient for resident activities and is enclosed with a self-latching gate.The facility has no bodies of water. The facility has sufficient lighting and is maintained at a comfortable temperature. Resident’s bathrooms were operating in safe and sanitary conditions. The hot water temperature in residents' bathrooms measured between 110 and 120 degrees F. Resident’s bedrooms have sufficient lighting and furniture in good repair. Facility has operating carbon monoxide alarms and telephone service. 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.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023

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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ABSOLUTE QUALITY CARE HOME	FACILITY NUMBER: 361800228
	VISIT DATE: 12/06/2023

NARRATIVE

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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. Pesticides 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.
Record Review: The facility did not have the following personnel records available to the licensing agency to inspect, audit, and copy upon demand: (3) complete staff files for review. The facility did not have readily available in a central administrative location: (2) complete resident files for review. The facility did not have documentation of quarterly emergency drill conducted with staff.

Medical Related Services: All medication is centrally stored and kept in a locked cabinet.

Based on LPA observations and record review, deficiencies were cited during today's visit, per Title 22, Division 6 of The California Code of Regulations.

An exit interview was conducted where reports (LIC809/LIC809-D/LIC9102) were discussed with Administrator Marchany. Copies of the reports with Appeal Rights were provided to the Administrator at the conclusion of the visit.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/06/2023 12:37 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ABSOLUTE QUALITY CARE HOME	FACILITY NUMBER: 361800228
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(f)

Personnel Records

(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA record review, the licensee did not comply with the section cited above by not maintaining record for (3) staff upon demand for licensing agency review, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/05/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator shall submit to the licensing agency (3) complete staff records for review by POC due date.

Section Cited

Criminal Record Clearance


	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) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023

LIC809 (FAS) - (06/04)

Page: 3 of 13

Document Has Been Signed on 12/06/2023 12:37 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ABSOLUTE QUALITY CARE HOME	FACILITY NUMBER: 361800228
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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 observations, the licensee did not comply with the section cited above by not maintaining documentation of quarterly emergency drill conducted with staff for licensing review, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/05/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator shall submit to the Licensing Agency documentation of emergency drill.

Type B

Section Cited

CCR

87506(a)

Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA record review, the licensee did not comply with the section cited above by facility did not have readily available in a central administrative location: (2) complete resident files for review, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/05/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator shall submit to the Licensing Agency (2) complete resident files for review 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 Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023

LIC809 (FAS) - (06/04)

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