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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880561
Report Date: 12/27/2023
Date Signed: 12/27/2023 04:28:47 PM

Document Has Been Signed on 12/27/2023 04:28 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:LAS PALMAS RESIDENTIAL CAREFACILITY NUMBER:
361880561
ADMINISTRATOR:MEDINA, RYANFACILITY TYPE:
735
ADDRESS:7128 LAS PALMAS DRTELEPHONE:
(909) 330-2231
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY: 6CENSUS: 4DATE:
12/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Licensee/Adminstrator Ryan MedinaTIME COMPLETED:
04:40 PM
NARRATIVE
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On 12/27/23 at 11:15 AM, Licensing Program Analysts (LPAs) Melody Brown & Bianca Wolcott arrived unannounced to conduct the required comprehensive annual visit to the facility. LPAs met with Licensee/Administrator Margarita Medina introduced themselves, and stated the purpose of the visit. Licensee/Adminstrator Ryan Medina arrived during the visit.

The facility has six (6) bedrooms, three (3) bathrooms, kitchen, dining room, living room, attached garage. The facility is vendorized by Inland Regional Center (IRC). LPAs
Brown & Wolcott completed a walkthrough of the facility, review of records, medication audit and P&I audit.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL), LPAs Brown & Wolcott observed three (3) clients. There are no obstructions to indoor & outdoor passageways. The facility is maintained at a comfortable temperature of 74 degrees F. LPAs Brown & Wolcott inspected client bedrooms; bathrooms were clean, and appliances were found functional. Water temperatures tested 115 degrees F. The facility is equipped with operational smoke detectors, carbon monoxide detectors, charged fire extinguisher, and first aid kit with first aid book. Furthermore, during the tour of the facility, LPAs Brown & Wolcott observed alteration made on the 2nd floor as two (2) rooms were added and per documents review, LPAs Brown and Wolcott observed no notification made to CCLD of the alteration made to the facility. Deficiency will be issued.

Posters such as; the personal rights, CCL complaint poster, emergency disaster plan were posted in a common area. Sharps and medications were kept in secure cabinets inaccessible to clients. The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility. Overall, the facility is clean, and operates in safe conditions for clients in care.

*** Continuation in LIC809C ***
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Bianca Wolcott
LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2023
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 22
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: LAS PALMAS RESIDENTIAL CARE
FACILITY NUMBER: 361880561
VISIT DATE: 12/27/2023
NARRATIVE
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Yards/Outside: One shaded patio, one (1) side gate with self-latching handle on the left side of the house that leads into the backyard. The outdoor pathway on the side of the facility was free of obstructions.

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

Care & Supervision: Facility has sufficient care staff for coverage 4 hours a day, 7 days a week.

Record Review: LPAs Brown & Wolcott, reviewed client files for Admission Agreements, Needs and Services Plans, Functional Capabilities, Pre-placement Appraisal and Physician Report (LIC602). LPAs Brown & Wolcott observed that C1, C2, C3 and C4 do not have the Needs and Services Plan, Functional Capabilities and Pre-placement Appraisal in their facility file. Deficiencies will be issued. LPAs also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, training's, and health screenings and Tuberculosis (TB) Test result. Per LPAs Brown and Wolcott records review, Staff #5(S5) does not have Health Screening Report in S5 file. Deficiency will be issued. LPA Brown reviewed C1,C2,C3, and C4 P&I records and LPAs Brown & Wolcott observed no issue. LPAs Brown & Wolcott reviewed C1 and C4 medications. LPAs Brown & Wolcott observed no issue. Moreover, LPAs Brown & Wolcott observed that Staff #4(S4) has a criminal record clearance but the facility did not transfer S4's criminal background clearance to the facility since 10/2021. Deficiency and civil penalty of $500.00 will be issued today, 12/27/2023.

Deficiencies were cited during the visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102 LIC421BG and Appeal Rights were discussed and copies were provided to Licensee/Administrator Ryan Medina.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Bianca Wolcott
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023
LIC809 (FAS) - (06/04)
Page: 2 of 22
Document Has Been Signed on 12/27/2023 04:28 PM - It Cannot Be Edited


Created By: Bianca Wolcott On 12/27/2023 at 02:50 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: LAS PALMAS RESIDENTIAL CARE
FACILITY NUMBER: 361880561

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
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: (10) A health screening as specified in Section 80065(g).

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 having Staff 5 (S5) health screening report completed and maintained in S5 staff file which pose a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/12/2024
Plan of Correction
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Licensee stated to submit a copy of S5 completed health screening report to LPAs Brown & Wolcott on POC due date.
Type B
Section Cited
CCR
85068.2(b)(1)(C)
Needs and Services Plan
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (C) The written medical assessment specified in Section 80069.

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 having the required Physician Report for Client #2 (C2) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/12/2024
Plan of Correction
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Licensee stated to submit copy of C2 Physician Report/Letter of Explanation
to LPAs Brown & Wolcott 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:Nedra Brown
LICENSING EVALUATOR NAME:Bianca Wolcott
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2023


LIC809 (FAS) - (06/04)
Page: 3 of 22
Document Has Been Signed on 12/27/2023 04:28 PM - It Cannot Be Edited


Created By: Bianca Wolcott On 12/27/2023 at 02:50 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: LAS PALMAS RESIDENTIAL CARE
FACILITY NUMBER: 361880561

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.2(b)(1)(G)1
Needs and Services Plan
1. The licensee shall document the initial assessment based on information available at the time of the assessment. This information shall be maintained and brought current thereafter as needed.

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 completing the required Needs and Services Plan for C1, C2, C3 and C4 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/12/2024
Plan of Correction
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Licensee stated to submit copies of the required Needs and Services Plan for C1, C2, C3 & C4 to LPAs Brown & Wolcott on POC due date.
Type B
Section Cited
CCR
80069.2(b)
Functional Capabilities Assessment
(b) Assessment of the client's need for assistance shall include consideration of his/her physical condition affecting participation in his/her own care, including:

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 completing the required Functional Capabilities Assessment for C1, C2, C3 and C4 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/12/2024
Plan of Correction
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Licensee stated to submit copies of completed functional cabilities asssessments for C1, C2, C3 & C4 to LPAs Brown & Wolcott 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:Nedra Brown
LICENSING EVALUATOR NAME:Bianca Wolcott
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2023


LIC809 (FAS) - (06/04)
Page: 4 of 22
Document Has Been Signed on 12/27/2023 04:28 PM - It Cannot Be Edited


Created By: Bianca Wolcott On 12/27/2023 at 03:31 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: LAS PALMAS RESIDENTIAL CARE
FACILITY NUMBER: 361880561

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80086(a)
Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change.

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 notifying CCLD of the proposed change prior to adding rooms in second floor of the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/29/2024
Plan of Correction
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Licensee stated to obtain permit from city or county agency for the alteration authorization at the facility & submit a letter to notify CCLD of the proposed change on POC due date.
Type B
Section Cited
CCR
80065(i)(2)
80065 Personnel Requirements-(i) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (2) Request a transfer of a criminal record clearance as specified in section 80019(f) or


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 by not transferring Staff #4 (S4) criminal background clearance to the facility prior to employment which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/12/2024
Plan of Correction
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Licensee submitted form LIC 9182 Criminal Background Clearance Transfer Request to LPAs Brown & Wolcott during the visit on 12/27/23, POC cleared.
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:Nedra Brown
LICENSING EVALUATOR NAME:Bianca Wolcott
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2023


LIC809 (FAS) - (06/04)
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