361880660-2-28-2025-56-AS-LFAW-DEC364-20250228165743

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361880660
Report Date: 02/28/2025
Date Signed: 02/28/2025 04:57:57 PM

Document Has Been Signed on 02/28/2025 04:57 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	RIALTO ASSISTED LIVING		FACILITY NUMBER:	361880660
ADMINISTRATOR/ DIRECTOR:	KYONG SUK LEE		FACILITY TYPE:	740
ADDRESS:	1441 S RIVERSIDE AVE		TELEPHONE:	(909) 877-2340
CITY:	RIALTO	STATE: CA	ZIP CODE:	92376
CAPACITY: 94	TOTAL ENROLLED CHILDREN: 0	CENSUS: 63	DATE:	02/28/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:50 AM
MET WITH:	Tae Kim, Administrator		TIME VISIT/ INSPECTION COMPLETED:	04:35 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, LaVette Farlow, (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 Library 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 Marketing Director, Irene Silva, 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 at 72 degrees Fahrenheit. LPA observed the hot water temperature in the kitchen, common area bathrooms and residents bathrooms. The water temperature in the residents bathroom and common area bathrooms measured at 119.6, 109.3, and 109.5, which is within regulations. The kitchen water measured at 126.9 which is out of regulations. LPA advised licensee to monitor the water temperature, resident are not at risk due to this being a restricted staff area. 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 2/19/25. No abnormal notes (LIC809C Continued)

Nedra Brown	TELEPHONE: (951) 202-5776
Lavette Farlow	TELEPHONE: 951-248-0304
	DATE: 02/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025

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

FACILITY NAME: RIALTO ASSISTED LIVING	FACILITY NUMBER: 361880660
	VISIT DATE: 02/28/2025

NARRATIVE

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made. Fire Extinguishers were observed throughout the facility. Fire Extinguishers were last inspected October 2024.
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.
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. LPA observed the facility has a current hospice waiver for four (4) resident and have eight (8) resident on hospice services. Licensee did inquired about the required step to increase the number of resident receiving hospice care with previous LPA. Unfortunately, the licensee did not complete the required steps. A deficiency was cited.
Record Review and Resident/Staff Files: LPA reviewed records for six (6) residents files currently living at the facility. Resident records are complete with updated physician reports and Needs and Services Plans. LPA additionally reviewed seven (7) staff files and six (6) out of (7) staff records reflect current CPR/First Aid Certification and Criminal Record Clearance. A technical violation was issued. LPA observed 3 out of 7 staff records missing a health screening report, missing a physician signature on the report, or the TB test results were not identified on the report. A technical violation was issued.
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. LPA observed that 4 out of 5 resident MAR was current and accurate. One resident file did not have 2 prescription properly logged. A deficiency was cited.

Based on observations, two deficiency cited and one technical violation issued 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: Lavette Farlow	TELEPHONE: 951-248-0304
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/28/2025 04:57 PM - It Cannot Be Edited

Created By: Lavette Farlow On 02/28/2025 at 03:58 PM

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
RIVERSIDE, CA 92507

FACILITY NAME: RIALTO ASSISTED LIVING	FACILITY NUMBER: 361880660
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(e)

Incidental Medical and Dental Care Services

(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. 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 in 1 out of 5 residents in care by not ensuring the MARS contains current and accurate information regarding residents medication. One resident MARS was missing two medications that was prescribed by the physician which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/07/2025
	Plan of Correction
1 2 3 4	Licensee agrees to complete a training on the proper procedure for ensuring the medication is logged on the MARS. Provide proof of training log for staff and proof of the regulation review by all staff by POC date.

Type A

Section Cited

CCR

87632(d)(2)

Hospice Care Waiver

(2) The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services. The notice shall include the resident's name and date of admission to the facility and the name and address of the hospice. 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 for 4 out of 8 residents in care by ensuring that the facility attained and or completed the required step to aquire a hospice waiver increase from 4 to 8 resident receiving hospice care which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/11/2025
	Plan of Correction
1 2 3 4	Licensee agrees to complete the hospice waiver increase to be in complaince with the regulations 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:

Nedra Brown

TELEPHONE: (951) 202-5776

LICENSING EVALUATOR NAME:

Lavette Farlow

TELEPHONE: 951-248-0304

LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025

LIC809 (FAS) - (06/04)

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