361880860-12-13-2024-56-AS-MMAE-DBWUBG-20241213142618

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361880860
Report Date: 12/13/2024
Date Signed: 12/13/2024 02:26:53 PM

Document Has Been Signed on 12/13/2024 02:26 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:	ALPHALIFE HOMECARE		FACILITY NUMBER:	361880860
ADMINISTRATOR/ DIRECTOR:	SALDIVAR, BRYANT J		FACILITY TYPE:	740
ADDRESS:	9154 BELLFAST ROAD		TELEPHONE:	(909) 601-5154
CITY:	APPLE VALLEY	STATE: CA	ZIP CODE:	92308
CAPACITY: 12	TOTAL ENROLLED CHILDREN: 0	CENSUS: 3	DATE:	12/13/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:40 AM
MET WITH:	Yanira Saldivar		TIME VISIT/ INSPECTION COMPLETED:	02:35 PM

NARRATIVE

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Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required comprehensive annual inspection. LPA met with Head Caregiver, Yanira Saldivar, was granted entry into the facility and discussed the purpose of the visit. The facility is a Residential Care Facility for Elderly (RCFE) with a licensed capacity of (12) and a current census (3). LPA conduct a overall inspection, which included, but was not limited to, the following:

Physical Plant: Indoor and outdoor passageways were kept free of obstruction. The facility has no swimming pool or similar bodies of water. The facility has sufficient space for resident activities and maintained at a temperature of 72 degrees F. LPA observed the covered fireplace in the living room near the kitchen area was covered in cobwebs. LPA inspected (4) resident bedrooms which were furnished with beds, bed linen, night stands, chairs and sufficient lighting. LPA observed resident #1 (R1) was utilizing a bed with half bed rails. Staff stated the R1 is no longer on Hospice and staff was not able to provide medical documentation for the use of half bedrails. LPA observed R1's ceiling fan was covered with dust. LPA inspected (3) resident bathrooms. The hot water temperatures in the bathrooms measured at 105 degrees F. LPA observed the bathroom floor and toilet in the bathroom located in near the kitchen area was not maintained clean. LPA observed bathroom sink and shower in resident #3's (R3) bathroom was not maintained cleaned. LPA observed a strong odor inside R3's bedroom. The facility is equipped with operating smoke/carbon monoxide alarms, laundry equipment, and telephone service. Posters such as personal rights, Community Care Licensing complaint poster, Ombudsman poster, facility license and emergency telephone numbers were posted in a common area. Cleaning supplies, toxins, and sharps were kept inaccessible to residents in care. There was a designated storage space for resident files.

Health Related Services: Medications were labeled and centrally stored in a locked cabinet, inaccessible to residents in care. LPA observed Resident #2 (R2) was out of their prescribed daily medication. Staff stated that R2 was not given their AM medication as they are waiting for their refill; which will arrive this afternoon.

Karen Clemons	TELEPHONE: (951) 248-0349
Magda Malcore	TELEPHONE: 951-248-0316
	DATE: 12/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2024

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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Document Has Been Signed on 12/13/2024 02:26 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: ALPHALIFE HOMECARE	FACILITY NUMBER: 361880860
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Infection Control Requirements

(a) A licensee shall ensure that infection control practices are maintained as follows: (2) Environmental cleaning and disinfection activities shall be performed following the manufacturers' instructions for proper use of the cleaning and disinfecting products. These activities shall be completed, at a minimum, as follows: (A) Surfaces such as floors, chairs, toilets, sinks, counters and tabletops shall be cleaned and disinfected on a regular basis to ensure they are safe and sanitary. These surfaces shall also be disinfected when these surfaces are contaminated and visibly soiled with blood or body fluids or other potentially infectious material. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above by not maintaining bathroom floors, sinks, and toilet clean; which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/16/2024
	Plan of Correction
1 2 3 4	Licensee shall submit to the licensing agency proof of cleaned bathroom by POC date.

Section Cited

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observations, the licensee did not comply with the section cited above by not maintaining Fireplace and Resident #1's ceiling fan; which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/16/2024
	Plan of Correction
1 2 3 4	Licensee shall submit to the licensing agency proof of cleaned kitchen equipment by POC due 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.

Karen Clemons	TELEPHONE: (951) 248-0349
Magda Malcore	TELEPHONE: 951-248-0316
	DATE: 12/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/13/2024 02:26 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: ALPHALIFE HOMECARE	FACILITY NUMBER: 361880860
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

General Food Service Requirements

(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observations the licensee did not comply with the section cited above by not maintaining kitchen stove, refrigerator, and compact freezer clean. Not maintaining kitchen counters free of clutter; which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/16/2024
	Plan of Correction
1 2 3 4	The Licensee shall submit proof of cleaned area mentioned by POC due date.

Section Cited

Incidental Medical and Dental Care Services

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above by not administering R2's AM medication as presribed; which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/16/2024
	Plan of Correction
1 2 3 4	The Licensee shall submit to the licensing agency proof of refilled medication by POC due 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.

Karen Clemons	TELEPHONE: (951) 248-0349
Magda Malcore	TELEPHONE: 951-248-0316
	DATE: 12/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/13/2024 02:26 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: ALPHALIFE HOMECARE	FACILITY NUMBER: 361880860
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observations, the licensee did not comply with the section cited above by not maintaining staff dementia/medication training, health screenings with Tuberculosis, and personal record (LIC501) for review; which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/13/2025
	Plan of Correction
1 2 3 4	The Licensee shall submit to the licensing agency documentation of the above by POC due date.

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.

Karen Clemons	TELEPHONE: (951) 248-0349
Magda Malcore	TELEPHONE: 951-248-0316
	DATE: 12/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/13/2024 02:26 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: ALPHALIFE HOMECARE	FACILITY NUMBER: 361880860
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Section Cited

(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 LPA observations, the licensee did not comply with the section cited above by not providing documention of staff first aid training for review; which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/13/2025
	Plan of Correction
1 2 3 4	The Licensee shall submit to the licensing agency documentation of staff first aid/CPR training by POC due 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.

Karen Clemons	TELEPHONE: (951) 248-0349
Magda Malcore	TELEPHONE: 951-248-0316
	DATE: 12/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/13/2024 02:26 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: ALPHALIFE HOMECARE	FACILITY NUMBER: 361880860
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observations, the licensee did not comply with the section cited above by not maintaining a current annual physician's assessement for all residents on file; which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/13/2025
	Plan of Correction
1 2 3 4	The Licensee shall submit to the Licensing Agency documentation of current medical assessments by POC date.

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.

Karen Clemons	TELEPHONE: (951) 248-0349
Magda Malcore	TELEPHONE: 951-248-0316
	DATE: 12/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2024

LIC809 (FAS) - (06/04)

Page: 6 of 20

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: ALPHALIFE HOMECARE	FACILITY NUMBER: 361880860
	VISIT DATE: 12/13/2024

NARRATIVE

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Food Service: The facility has a sufficient supply of non-perishable and perishable food for number of residents in care. A weekly menu posted in the kitchen area. LPA observed kitchen counters were cluttered with dishes and pots. Kitchen stove, kitchen refrigerator (inside), compact freezer (located near dining area) were not maintained clean.

Record Review: LPA reviewed three (3) resident files for admission agreements, updated physician reports, and needs and services plans. LPA record reveals all three residents did not have a current annual physician's assessment. Staff was unable to find staff files which contain first Aid/CPR certifications, job training, employee record (LIC501) and health screenings with tuberculosis results for LPA to review.

During today's visit, deficiencies and technical advisories were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted where reports (LIC809, LIC809-D, LIC9102) and correction plans were discussed. Copies with appeal rights provided to Lead Staff at the conclusion of the visit.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/13/2024 02:26 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: ALPHALIFE HOMECARE	FACILITY NUMBER: 361880860
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Managed incontinence (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above by not maintaining R1's bedroom odor free; which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/16/2024
	Plan of Correction
1 2 3 4	The Licensee shall submit proof of correction by POC due date.

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.

Karen Clemons	TELEPHONE: (951) 248-0349
Magda Malcore	TELEPHONE: 951-248-0316
	DATE: 12/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2024

LIC809 (FAS) - (06/04)

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