361880589-7-24-2024-56-AS-MBRN-D7GSC4-20240724134454

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361880589
Report Date: 07/24/2024
Date Signed: 07/24/2024 01:45:24 PM

Document Has Been Signed on 07/24/2024 01:45 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME:	SANDALWOOD MANOR		FACILITY NUMBER:	361880589
ADMINISTRATOR:	DILLARD, JACQUELINE		FACILITY TYPE:	740
ADDRESS:	7602 PURPLE SAGE CIR		TELEPHONE:	(909) 600-7028
CITY:	FONTANA	STATE: CA	ZIP CODE:	92336
CAPACITY:	4	CENSUS: 1	DATE:	07/24/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Licensee/Administrator Jacqueline Dillard		TIME COMPLETED:	01:45 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	On 07/24/2024 at 10:00 AM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Brown met with Licensee/Administrator Jacqueline Dillard and was granted entry to the facility. At the time of the visit, there were two (2) staff present, and one (1) resident present. The facility is a two (2) bedroom, one (1) bathroom home with a kitchen/dining area, living room/activity room and a garage. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of four (4) non-ambulatory residents. The facility’s approved for four (4) hospice waiver. The current census is one (1) resident. LPA Brown was accompanied by Licensee/Administrator Dillard 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 78 degrees Fahrenheit (F). LPA Brown inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathroom was clean, and appliances were operating appropriately. LPA Brown observed sufficient furniture and lighting throughout the facility. LPA Brown measured and observed the water temperatures in the bathroom to be at 100.3 degrees F. Deficiency will be issued. During the visit, Licensee/Administrator Dillard regulated/adjusted the water temperature to 106 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Fire extinguishers were also observed at the facility. Posters such as personal rights, the CCLD complaint poster, labor laws, and the disaster plan were posted in a common area. *Continuation in LIC809C *

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024

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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: SANDALWOOD MANOR	FACILITY NUMBER: 361880589
	VISIT DATE: 07/24/2024

NARRATIVE

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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 Cabinet with the resident medications locked. LPA Brown observed a 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 an Administrator present during the visit. However, LPA Brown observed no staff scheduled to work the night shift, awake and on duty as required for facility with dementia residents. Deficiency will be issued.

Record Review: LPA Brown reviewed one (1) resident file for admission agreement, updated physician report, and pre-placement appraisal. LPA Brown observed resident file reviewed was complete. LPA Brown reviewed two (2) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test. LPA Brown noted that staff files reviewed were complete. LPA Brown audited Resident #1 (R1) medications and LPA Brown observed that one (1) of R1 medication was not given per R1's physician direction as LPA Brown found discrepancy on one (1) of R1's medication quantity per facility record. 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 Licensee/Administrator Jacqueline Dillard.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/24/2024 01:45 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: SANDALWOOD MANOR	FACILITY NUMBER: 361880589
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(c)(2)

Incidental Medical and Dental Care Services

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, (interview and record review, the licensee did not comply with the section cited above by not dispensing Resident #1 (R1) medication according to R1 Physician's directions as evidenced of incorrect quantity of one (1) bottle of medicine per number of days given in reference to R1's Physician direction which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/25/2024
	Plan of Correction
1 2 3 4	Licensee stated to train all staff on CCR 87705(c)(4)(A) and submit proof of Staff Training Log to LPA Brown on Plan of Correction (POC) due date.

Type A

Section Cited

CCR

87705(c)(4)(A)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident's physical, social, emotional, safety and health care needs as identified in his/her current appraisal. (A) In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal or observation to require awake night supervision. 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 there's a staff scheduled to work the night shift, awake and on duty as required for facility with dementia residents which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/25/2024
	Plan of Correction
1 2 3 4	Licensee stated to submit an updated Personnel Report (LIC500) showing a staff scheduled to work the night shift to LPA Brown 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: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/24/2024 01:45 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: SANDALWOOD MANOR	FACILITY NUMBER: 361880589
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that the hot water is regulated/adjusted to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C) which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/29/2024
	Plan of Correction
1 2 3 4	Licensee adjusted/regulated the hot water to 106 degree Fahrenheit (F) during the visit. Plan of Correction (POC) cleared.

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: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024

LIC809 (FAS) - (06/04)

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