361880660-1-25-2024-56-AS-ACON-CZTVXS-20240125155001

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361880660
Report Date: 01/25/2024
Date Signed: 01/25/2024 03:50:15 PM

Document Has Been Signed on 01/25/2024 03:50 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: 55	DATE:	01/25/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Tae Kim, Administrator		TIME COMPLETED:	04:00 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 and stated purpose of the visit. LPA met with Administrator, Tae Kim, who accompanied LPA on a tour of the facility and provided LPA with 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 to be maintained at a comfortable temperature. LPA observed resident, staff and guests restrooms all included operable appliances, adequate amounts of hand hygiene and paper supplies. The facility houses a laundry room ran by housekeeping staff; this room was observed to have operational appliances and is secure.. LPA observed that linens and hygiene items are enough for the amount of residents in care. Each resident room included sufficient lighting via lamps and night-lights to ensuring residents comfort and safety. The facility is equipped with a functional smoke/fire alarm system and carbon monoxide detectors. The facility maintains a contract with a third party company who inspects the fire alarm system, fire extinguisher conducts fire/disaster drills on a quarterly basis. Fire Extinguishers were observed throughout the facility all last inspected October 2023. Food Service: Nonperishable and perishable food items observed were in good standing and sufficient for number of residents in care. LPA's walk through occurred during snack time. LPA observed that food is being prepared and stored properly. Rialto Assisted Living Facility offers a variety of food options and snacks for residents in care. LPA observed posters for meal and snack times. Also a food menu posted in a prominent place.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024

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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: RIALTO ASSISTED LIVING	FACILITY NUMBER: 361880660
	VISIT DATE: 01/25/2024

NARRATIVE

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Care & Supervision: Facility has sufficient care staff. LPA observed that toxic items and cleaning supplies are inaccessible to residents; and stored and kept securely throughout the facility.
Record Review and Resident/Staff Files: LPA reviewed resident records residents for Updated Physician's Reports, Admissions Agreements and Needs and Services Plans. LPA observed that 2 records were out of compliance. LPA additionally reviews staff records for current CPR/First Aid Certification and Criminal Record Clearance.
Administration: Disaster Plan, Resident/Personal Rights, LTC Ombudsman poster, Administrator Certificate, facility sketch/evacuation plan, infection control 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 secure 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: 01/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/25/2024 03:50 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: 01/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87548(a)

87548 Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. 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 each resident had an updated Physician's Report (LIC602) completed and included in each resident file for two, (2) residents which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/26/2024
	Plan of Correction
1 2 3 4	Administrator/Licensee agree to assist the resident's with making and keeping an appointment with their Primary Physicians' to get each of their Physician's Reports completed. Administrator/Licensee agrees to send confirmation these LIC602 forms have been completed 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: 01/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024

LIC809 (FAS) - (06/04)

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