361880638-4-14-2022-56-AS-MBRN-CDGNL2-20220414103250

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361880638
Report Date: 04/14/2022
Date Signed: 04/14/2022 10:33:15 AM

Document Has Been Signed on 04/14/2022 10:33 AM - 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:	PINE RESIDENTIAL CARE		FACILITY NUMBER:	361880638
ADMINISTRATOR:	IGARTA, ALICIA		FACILITY TYPE:	735
ADDRESS:	17269 PINE AVE		TELEPHONE:	(909) 333-1356
CITY:	FONTANA	STATE: CA	ZIP CODE:	92335
CAPACITY: 4		CENSUS: 4	DATE:	04/14/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Jake Hammond		TIME COMPLETED:	10:45 AM

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) Melody Brown arrived at the facility 04/14/2022 at 8:30 AM unannounced in order to complete the facility's Annual Inspection. LPA Brown met with Staff Jake Hammond and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. Administrator Alicia Igarta was contacted and informed of the visit. Below is a summary of what was observed: Infection Control: LPA Brown went over COVID-19 best practices for infection control and prevention with staff Hammond. Per documents review, Mitigation Plan was submitted 07/21/2021. LPA Brown observed the facility having Covid-19 signages throughout the facility for proper hand washing procedure and social distancing. LPA Brown toured the facility's resident bedrooms and bathrooms and observed that both resident bathrooms have hand soap and individual hand towel issued to each client due to reported client incident with paper towels. LPA Brown requested to inspect the facility's Personal Protective Equipment (PPE) supply. LPA Brown observed the facility to have a sufficient supply of sanitizer, gloves, masks, isolation gowns but no face shields/goggles. LPA Brown will be issuing a Technical Assistance Advisory Note instead of a deficiency due it being difficult to access face shields at numerous points during the COVID-19 pandemic. LPA Brown advised the facility to look online for items missing from their PPE supply kit, as Community Care Licensing Department (CCLD) and Inland Regional Center (IRC) may not have these items to supply them with. LPA Brown went over the various recommended training for facility staff with staff Hammond in relation to COVID-19 and staff Hammond informed LPA Brown that all staff are trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing of PPE. ** Continuation in LIC809C **

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

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: PINE RESIDENTIAL CARE	FACILITY NUMBER: 361880638
	VISIT DATE: 04/14/2022

NARRATIVE

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During the visit, LPA Brown observed Staff 8 not wearing a mask and LPA Brown requested Staff 8 to wear a mask. As of today's date, Community Care Licensing Department (CCLD) is still recommending for all staff to continue to wear a mask when inside the facility. LPA Brown will be issuing a Technical Assistance Advisory Note for staff not wearing mask while inside the facility.

LPA Brown inquired as to if staff have been fit tested for N95 masks, and staff Hammond informed LPA Brown that at this time staff have not been fit tested. LPA Brown will be issuing a Technical Assistance Advisory Note during today's inspection for staff not being fit tested for N95 masks. LPA Brown will not be issuing a deficiency for this item due to the facility not currently having any COVID-19 positive clients, and N95 masks only needing to be worn when a client is COVID-19 positive or under observation while awaiting test results. Additionally, most clients have been vaccinated and are practicing other COVID-19 precautions, which minimize the risk of them contracting COVID-19. LPA Brown will be providing staff Hammond with the information for Provider Information Notice (PIN) PIN-21-10-ASC which contains resources for getting staff fit tested for N95 masks.

The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the proper use and disposal of PPE and overall infection control. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and their clients, when and how to isolate/quarantine clients, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas. The facility also has a plan in place to monitor their clients regularly for any changes in condition and to subsequently notify the cleint's physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses.

**** Continuation in LIC809C ****

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

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: PINE RESIDENTIAL CARE	FACILITY NUMBER: 361880638
	VISIT DATE: 04/14/2022

NARRATIVE

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During the visit, LPA Brown requested staff vaccination records and on 04/14/2022 at 09:15 AM, LPA Brown observed no staff vaccination record/Exemption at the facility except for Staff 8 and no record of Booster/Exemption for all Staff (S1-S14) at the facility as well. Administrator Alicia Agarta was contacted, and she confirmed that no Staff Vaccination/Exemption record at the facility and no Booster/Exemption record at the facility as well. Administrator Agarta said that she will email LPA Brown the copies of all their staff Vaccination/Booster/Exemption records to LPA Brown. LPA Brown will be issuing a deficiency for failure to keep records of Worker’s Vaccination/Booster/Exemption which can pose potential risk to residents in care.

An exit interview was conducted with staff Jake Hammond and a copy of this report (LIC809), LIC 809D, LIC9102 TA Advisory Notes and Appeal Rights were discussed and provided.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/14/2022 10:33 AM - It Cannot Be Edited

Created By: Melody Brown On 04/14/2022 at 10:05 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
, CA 92507

FACILITY NAME: PINE RESIDENTIAL CARE	FACILITY NUMBER: 361880638
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

121125,120140,120276

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 the personal rights of persons in care to live in a safe, healthy, comfortable home failed to comply with reporting and personnel requirements and engaged in conduct inimical to the health, welfare, and safety of persons in care in that Licensee did not verify, worker's vaccination, booster or exemption status or unvaccinated worker's test results as applicable by maintaining a record as required by State Public Officer Order of December 22, 2021 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/21/2022
	Plan of Correction
1 2 3 4	Licensee stated that they will submit proof of Vaccination/Exemption of Staff 1-7 and Staff 10-14 and proof of Booster Vaccination/Exemption of all staff - Staff 1-14 to LPA Brown by POC due date and update Staff Vaccination/Booster/Exemption Record at the facility by POC due 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:

Efren Malagon

LICENSING EVALUATOR NAME:

Melody Brown

LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

LIC809 (FAS) - (06/04)

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