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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800429
Report Date: 05/01/2023
Date Signed: 05/01/2023 12:17:39 PM

Document Has Been Signed on 05/01/2023 12:17 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:HELPING HEARTS BONANZAFACILITY NUMBER:
361800429
ADMINISTRATOR:MANUEL SOTOFACILITY TYPE:
772
ADDRESS:14516 BONANZA ROADTELEPHONE:
(909) 771-9940
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 10CENSUS: 10DATE:
05/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Administrator Frank PesqueiraTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA), Victoria Chitgian, made a visit to the facility to conduct an annual licensing inspection. Analyst was granted entry into the facility and met with Frank Pesqueira, Administrator. A tour of the facility was conducted. Licensee is providing each consumer with clean linen in good repair, and sufficient hygiene products for personal use. A comfortable temperature is maintained in the facility at the time of visit. The last disaster drill was conducted on 4/26/23. Hot water temperature in the bathroom measured at 117 degrees F. Kitchen water temperature was measured below required limit of 105. LPA issued Technical Violation. The facility is stocked with a two (2) day supply of perishable and seven (7) day supply of nonperishable food items. Food is being prepared and stored properly. Medications are stored in a locked closet in the hallway and administered according to the label instructions. Sufficient staff are employed and present in the facility to meet the needs of the consumers in care. All staff have a criminal record clearance, however First Aid certificates were not available for viewing. Deficiency issued. Administrator has secured each consumer’s personal property and cash resources. Each consumer file was reviewed. Records contained Admission Agreement, ambulatory status, however one client did not have a tuberculosis test result, as required. Deficiency was issued. The Administrator is on the premises a sufficient number of hours to adequately administer the facility in compliance with applicable law and regulation.
The facility did not have a written disaster and mass casualty plan to review. Administrator stated there must be a plan in place the main office, however there is not a copy at the physical facility. Deficiency was issued. LPA did see a floor plan posted in a common area along with other required signs and postings, such as the visitation policy.

Based on today’s inspection, four (4) deficiencies were observed at this time in the areas evaluated. One technical violation for the water temperature. An exit interview was conducted and this report, LIC 809, LIC 809-D, LIC 9182 and appeal rights was provided to Administrator Frank Pesqueira at the end of the visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Victoria Chitgian
LICENSING EVALUATOR SIGNATURE: DATE: 05/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/01/2023
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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Document Has Been Signed on 05/01/2023 12:17 PM - It Cannot Be Edited


Created By: Victoria Chitgian On 05/01/2023 at 11:47 AM
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 BONANZA
FACILITY NUMBER: 361800429

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
81069(f)(1)
Client Medical Assessments
(f) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/ infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as Client 1 did not have a tuberculosis examination in the record book, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/08/2023
Plan of Correction
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Administrator will produce a tuberculosis examination and result to LPA by POC due date above.
Type B
Section Cited
CCR
81075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above as the staff present at the facility do not have record of First Aid training, which poses potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2023
Plan of Correction
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Administrator shall provide records of First Aid training of staff present by POC due date 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:Efren Malagon
LICENSING EVALUATOR NAME:Victoria Chitgian
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 05/01/2023 12:17 PM - It Cannot Be Edited


Created By: Victoria Chitgian On 05/01/2023 at 11:47 AM
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 BONANZA
FACILITY NUMBER: 361800429

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
81023(a)
Disaster and Mass Casualty Plan
(a) Each licensee shall have and maintain on file a current, written disaster and mass casualty plan of action.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the facility did not comply with the section cited aboveas a written disaster and mass casualty plan was not available for review, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/08/2023
Plan of Correction
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Facility shall produce a written disaster and mass casualty plan and submit proof to LPA by POC due date above via email.
Type B
Section Cited
CCR
81023(b)(2)
Disaster and Mass Casualty Plan
(2) Contingency plans for action during fires, floods, and earthquakes, including but not limited to the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the facility did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/08/2023
Plan of Correction
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Facility shall produce a written plan for fire, floods, earthquakes to LPA by POC due date above via email.
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:Efren Malagon
LICENSING EVALUATOR NAME:Victoria Chitgian
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2023


LIC809 (FAS) - (06/04)
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