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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880834
Report Date: 11/02/2021
Date Signed: 11/02/2021 01:43:40 PM

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
RIVERSIDE, CA 92507
FACILITY NAME:I AM SENIOR HOME 1FACILITY NUMBER:
361880834
ADMINISTRATOR:NESTOR DOCE YODONGFACILITY TYPE:
740
ADDRESS:13560 COBALT ROADTELEPHONE:
(760) 493-1852
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY:6CENSUS: 5DATE:
11/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Juliet Kotoken-AguilarTIME COMPLETED:
01:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility to conduct an annual inspection, with emphasis on infection control. LPA Brown was greeted and granted entrance by caregiver Juliet Kotoken-Aguilar and LPA Brown explained the purpose of today's visit. Administrator Nestor Doce Yodong was contacted but unable to come to the facility for the inspection. Caregiver Juliet Kotoken-Aguilar accompanied LPA Brown on a tour of the inside and outside of the facility.

During today’s visit, LPA Brown made observation pertaining to the facility’s current infection control measures. LPA Brown observed a screening area, proper signages throughout the facility, sufficient hand hygiene supplies, cleaning supplies, and a sufficient supply of Personal Protective Equipment (PPE). The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, cleaning and disinfection are in adequate quantities, and that staff are trained in 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 residents for COVID-19, when and how to isolate/quarantine residents, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas/surfaces. The facility also has a plan in place to monitor residents regularly for any changes in condition and to subsequently notify the resident’s physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses. During the outside tour of the facility, LPA Brown observed locked perimeter fence gate, which the caregivers reported they do not know that they are not supposed to lock the perimeter fence gate. Caregiver Harriet Salawon also present during the inspection reported that 2 of 5 of their residents has mild dementia. The facility does not have approval for any form of locked perimeter, and this locking is not permitted, as residents might not be able to exit in an emergency. LPA Brown informed caregiver Katonen-Aguilar and caregiver Salawon that lock needs to be removed immediately.

An exit interview was conducted with caregiver Juliet Kotoken-Aguilar and a copy of this report (LIC 809) and LIC809D, appeal rights were provided.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
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
RIVERSIDE, CA 92507

FACILITY NAME: I AM SENIOR HOME 1
FACILITY NUMBER: 361880834
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(l)(2)


This requirement is not met as evidenced by: Based on observation and interview with caregivers, the Licensee did not comply with the regulation by locking the perimeter fence gate in a manner that residents are unable to exit without assistance. This poses an immediate hazard to all residents in care.
Deficient Practice Statement
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CCR - 87705 Care of Persons with Dimentia: (1) The following initial and continuing requirements shall be met by the licensee to lock the exterior doors or perimeter fence gates: (2) The Licensee shall ensure that the Fire Clearance includes approval of locked exterior doors or locked perimeter fence gates.
POC Due Date: 11/02/2021
Plan of Correction
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Licensee agrees to remove the lock and agree to not lock the perimeter fence gate without LIcensing and Fire Marshall approval. Caregiver unlocked gate during visit. Plan of Correction (POC) cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2021
LIC809 (FAS) - (06/04)
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