361880660-6-20-2023-56-AS-ACON-CSYUPY-20230620154618

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361880660
Report Date: 06/20/2023
Date Signed: 06/20/2023 03:46:24 PM

Document Has Been Signed on 06/20/2023 03:46 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:	RIALTO ASSISTED LIVING		FACILITY NUMBER:	361880660
ADMINISTRATOR:	KYONG SUK LEE		FACILITY TYPE:	740
ADDRESS:	1441 S RIVERSIDE AVE		TELEPHONE:	(909) 877-2340
CITY:	RIALTO	STATE: CA	ZIP CODE:	92376
CAPACITY:	94	CENSUS: 54	DATE:	06/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Tae Kim, Administrator		TIME COMPLETED:	03:45 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	Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Rialto Assisted Living Facility unannounced to conduct an Annual Inspection. LPA introduced self to staff and stated purpose of the visit. Staff informed Administrator, Tae Kim of LPA's visit and came to the front to meet with LPA. LPA discussed the purpose of the visit. LPA signed in and was provided a space to work. During today's visit, LPA completed a walk through of the facility with the Administrator, conducted staff and resident interviews and review of staff and resident files. LPA observed the following: Physical Plant: LPA observed the facility's temperatures to be comfortable and measured the hot water temperature in the kitchen at within regulation. LPA observed bathrooms and found that showers and toilets are operable. Each bathroom contained adequate amounts of hand hygiene and paper products. The facility houses a laundry room ran by housekeeping staff. LPA observed that linens and hygiene items are enough for residents in care. Each resident room included lamps, night-lights and appropriate lighting to ensure residents comfort and safety. The facility is equipped with smoke alarms and carbon monoxide detectors. The facility maintains a contract with a third party company who conducts fire/disaster drills on a monthly basis. Last drill completed on 6/16/23. No abnormal notes made. Fire Extinguishers were observed throughout the facility. Fir Extinguishers were last inspected October of 2022. Food Service: Nonperishable and perishable food items observed were sufficient for number of residents in care. Food is being prepared and stored properly. Facility offers a variety of food options and snacks for residents. Kitchen Staff maintain a food menu which is updated on a monthly basis.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

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: RIALTO ASSISTED LIVING	FACILITY NUMBER: 361880660
	VISIT DATE: 06/20/2023

NARRATIVE

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Care & Supervision: Facility has sufficient care staff; toxic items are inaccessible to residents in care and stored and kept secure in closets throughout the facility.
Record Review and Resident/Staff Files: LPA reviewed records for all five (5) residents currently living at the facility. Resident records are complete with updated physician reports and Needs and Services Plans. LPA additionally reviewed all five (5) staff files and four (4) out of (5) staff records reflect current CPR/First Aid Certification and Criminal Record Clearance.
Administration: Disaster Plan, Ombudsman poster, Administrator Certificate, and facility license are posted in a prominent place. Emergency Disaster Plan is current. Facility files are maintained in secure locations throughout the facility.
Medication/Medical Related Services: LPA observed that the residents' medication is centrally stored and locked in a Medications Room; managed by Medication Technicians.

Based on observations, a deficiency will be cited per Title 22, California Code of Regulations. An exit interview conducted and copy of this report reviewed and discussed, then provided to Administrator, Tae Kim

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/20/2023 03:46 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: RIALTO ASSISTED LIVING	FACILITY NUMBER: 361880660
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(c)(1)

(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record reviews, the licensee did not comply with the section cited above by not ensuring a member of the staff had all required documented training; which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/20/2023
	Plan of Correction
1 2 3 4	Administrator will assist staff in getting their CPR/First Aid Certificate updated to good standing. Once completed Administrator will submit verfication of CPR/First Aid training to the Community Care Licensing Office within the next 30 business days.

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: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

LIC809 (FAS) - (06/04)

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