361880612-10-19-2023-56-AS-MMAE-CWRR7X-20231019124705

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361880612
Report Date: 10/19/2023
Date Signed: 10/19/2023 12:47:22 PM

Document Has Been Signed on 10/19/2023 12:47 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:	HAMILTON HOME		FACILITY NUMBER:	361880612
ADMINISTRATOR:	VANCE, KIERSTEN		FACILITY TYPE:	740
ADDRESS:	940 STILLMAN AVE		TELEPHONE:	(909) 801-7055
CITY:	REDLANDS	STATE: CA	ZIP CODE:	92374
CAPACITY:	18	CENSUS: 15	DATE:	10/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Regina Chavez, Administrator		TIME COMPLETED:	12:40 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 Regina Chavez, Administrator, and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE). License capacity of (18) with a current census of (15) residents. LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: LPA inspected the facility inside and out. Indoor and outdoor passageways are free of obstruction. The facility has sufficient lighting and indoor space for resident activities. Facility is maintained at a comfortable temperature. Facility has no outdoor bodies of water. Facility backyard is enclosed with self-closing gates and covered patio is sufficient for outdoor resident activities. LPA inspected the kitchen. The refrigerator and freezer are operating in a healthful manner. Hot water temperature is maintained at 106 degrees F. Facility has sufficient non-perishable and perishable food supply for residents in care. Facility has sufficient cups, plates, and utensils for residents. Kitchen is clean and litter free. Facility food is stored in a safe and healthful manner. LPA inspected resident bedrooms. Bedrooms are equipped with beds, chairs, storage space, linen and sufficient lighting. LPA inspected resident bathrooms. Bathroom equipment is operating in a safe and sanitary condition. Bathroom hot water temperatures tested between 105 and 108 degrees F. LPA observed the facility is equipped with operating carbon monoxide alarms and telephone service. LPA observed posted in a common area: Resident activities, Licensing complaint poster, Ombudsman poster, emergency plans and telephone numbers. A fire drill was conducted on 9/23/23. Facility has a complete first aid kit.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023

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: HAMILTON HOME	FACILITY NUMBER: 361880612
	VISIT DATE: 10/19/2023

NARRATIVE

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The facility has sufficient linen, towels, emergency supplies, toileting and personal hygiene products for residents. Sharps, disinfectants, cleaning solutions, and toxins are kept in a locked cabinet.
LPA observed medications were kept safe and locked in a cabinet and inaccessible to residents in care. LPA audited medications for (4) residents. Resident 1 (R1) was out of their p.m. medication on 10/18/23 and not given to the resident as prescribed. Administrator stated that medication has been ordered and will arrive today 10/19/23. Deficiency cited.
LPA reviewed (4) staff files for training, fingerprint clearances/exemptions, health screening and employee background records. Staff 4 (S4) had a incomplete health screening in their facility files. Deficiency cited.
LPA reviewed (4) resident files for admissions agreements, physician's reports, assessments, and personal rights. Resident 2 (R2) physician's report was missing pages 4, 5, and 6 which contains resident's ambulatory or nonambulatory status, bedridden status, physical condition, mental conditions, and physician's name and signature. Administrator stated that will check with Hospice for a complete report.
Deficiencies were cited during today's visit and a plan of correction was discussed with Administrator Chavez.
An exit interview was conducted and copies of the discussed licensing reports were provided with appeal rights 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: 10/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/19/2023 12:47 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: HAMILTON HOME	FACILITY NUMBER: 361880612
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/19/2023

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 LPA observation, the licensee did not comply with the section cited above by residents' medication not given as prescribed which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/20/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator shall submit to the licensing agency proof correction by photo or a self-certified statement that the deficiency has been corrected by POC date.

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: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/19/2023 12:47 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: HAMILTON HOME	FACILITY NUMBER: 361880612
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/19/2023

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 staff #4 (S4) not having a complete health screening on file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/03/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator shall submit to the licensing agency proof of staff completed health screening by POC 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: 10/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/19/2023 12:47 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: HAMILTON HOME	FACILITY NUMBER: 361880612
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(b)(5)

Medical Assessment

(b) The medical assessment shall include, but not be limited to: (5) The determination whether the person is ambulatory or nonambulatory as defined in Section 87101(a) or (n), or bedridden as defined in Section 87455(d). The assessment shall indicate whether nonambulatory status is based upon the resident's physical condition, mental condition or both. 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 2 (R2) physician's report was missing pages 4, 5, and 6 which contains resident's ambulatory or nonambulatory status, bedridden status, physical condition, mental conditions, and physician's name and signature, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/03/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator shall submit to the licensing agency proof of completed medical assessment by POC date.

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: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023

LIC809 (FAS) - (06/04)

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