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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880686
Report Date: 05/15/2023
Date Signed: 05/15/2023 10:26:10 AM

Document Has Been Signed on 05/15/2023 10:26 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:HELPING HEARTS BLACKWOODFACILITY NUMBER:
361880686
ADMINISTRATOR:CESAR ARGUETAFACILITY TYPE:
772
ADDRESS:11253 BLACKWOOD STTELEPHONE:
(909) 677-6644
CITY:FONTANASTATE: CAZIP CODE:
92337
CAPACITY: 6CENSUS: 4DATE:
05/15/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:41 AM
MET WITH:Arthur Estrada - Program DirectorTIME COMPLETED:
10:27 AM
NARRATIVE
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to conduct a case management visit in relation to incident reports regarding missed medication. LPA met with program director Arthur Estrada and personnel director Jessica Zepeda arrived shortly.

On 4/27/23, program director was notified by staff that Client 1 was not administered their 4/26/23 scheduled evening medication but was otherwise marked as given. On 5/2/23, program director was notified by staff that Client 1 and Client did not receive their 5/1/23 scheduled evening medication. Program administrator stated that there were different staff for either incident.

LPAs Bueno and Amber Coleman last visited the facility on 10/28/2023 for a similar incident. LPAs were advised that an in-service training was completed for this incident. During today’s visit, LPA Bueno reviewed staff records. LPA found no records of in-service training conducted by a licensed professional. This poses a potential health and safety risk to clients in care

An exit interview was conducted where this report, LIC 809D, and appeal rights were discussed with and provided to Mr. Estrada.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 05/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2023
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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Document Has Been Signed on 05/15/2023 10:26 AM - It Cannot Be Edited


Created By: Anna Bueno On 05/15/2023 at 10:12 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: HELPING HEARTS BLACKWOOD
FACILITY NUMBER: 361880686

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/31/2023
Section Cited
CCR
81075(o)(3)

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The licensee shall ensure that facility staff responsible...received training from a licensed professional sufficient to meet the need... The licensed professional must be authorized by law to administer medication, including but no limited to a registered nurse, licensed vocational nurse, or psychiatric technician.
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Licensee shall submit proof of medication administration training by a licensed professional no later than the end of the POC date.
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This requirement was not met as evidenced by:

LPA found no training records conducted by a licensed professional.
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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
LICENSING EVALUATOR NAME:Anna Bueno
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2023


LIC809 (FAS) - (06/04)
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