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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880877
Report Date: 02/16/2024
Date Signed: 02/16/2024 05:17:31 PM

Document Has Been Signed on 02/16/2024 05:17 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:BIG HEARTS LOMAS VERDES, INC.FACILITY NUMBER:
361880877
ADMINISTRATOR:SCHAEFER, EVELINAFACILITY TYPE:
735
ADDRESS:25586 LOMAS VERDES STTELEPHONE:
(909) 328-2009
CITY:LOMA LINDASTATE: CAZIP CODE:
92354
CAPACITY: 4CENSUS: 4DATE:
02/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Alice Munde - Certified Medical AssistantTIME COMPLETED:
05:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced required 1-year visit to the facility. LPA met with Alice Munde, Certified Medical Assistant (CNA) and discussed the purpose of the visit.

The facility is an Adult Residential Facility (ARF), level 4i designated facility, certified by Inland Regional Center (IRC). Licensed capacity of (4) with a current census (4). LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:

Physical Plant: LPA inspected the facility inside and out. Indoor and outdoor passageways are kept free of obstruction. The facility's swimming pool is empty and enclosed by a locked fence. The facility's backyard is fenced with self-latching gates. The facility's living room, dining room, and activities room have sufficient space for client use. The facility has operating telephone service and carbon monoxide alarms. Client activities include day program participation, puzzles, supervised outdoor walks, watching movies, listening to music and community outings. Client bedrooms are equipped with furniture in good repair and sufficient lighting. Client bathrooms are operating in a safe and sanitary manner. The hot water temperature tested at 108 degrees F. The facility has sufficient blankets, linen, and personal hygiene products for clients in care. The facility has posted in a common area, emergency contact numbers, facility license, and Community Care Licensing poster.

Food Service: The facility has sufficient non-perishable and perishable food for number of clients in care. The facility freezer and refrigerator are operating in a healthful manner. Facility food is stored in a safe and healthful manner. Sharps, disinfectants, and other chemicals are kept locked and inaccessible to clients in care.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/16/2024
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: BIG HEARTS LOMAS VERDES, INC.
FACILITY NUMBER: 361880877
VISIT DATE: 02/16/2024
NARRATIVE
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 Care and Supervision: The facility has 24-hour/7 days a week care staff. The two (2) staff present at the facility had criminal record clearance through the Department's Guardian website.

Health-Related Services: All client medications are labeled and centrally stored. Medications are kept in a locked room and inaccessible to clients in care.

Record Review: The facility conducted a fire/earthquake drill with staff on 2/01/2024. LPA review of (4) client files reveals, the facility did not maintain record of client's cash transactions at the facility as the administrator has the records and is currently out of town. Deficiency cited. Staff files where not available for LPA review as the Administrator has the records and is currently out of town. Deficiency cited. Administrator certification expired on 10/18/23. The facility did not maintain record of the Administrator's application status or copy of current Administrator's certification for review. Deficiency cited.

Based on LPA observations and record review, deficiencies are being cited as per Title 22, Division 6 of the California Code of Regulations.

An exit interview was conducted where the licensing reports were discussed with CNA, Munde. Copies of the reports were provided with Appeal Rights to CNA, Munde as the conclusion of the visit.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024
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Document Has Been Signed on 02/16/2024 05:17 PM - It Cannot Be Edited


Created By: Magda Malcore On 02/16/2024 at 04:21 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: BIG HEARTS LOMAS VERDES, INC.
FACILITY NUMBER: 361880877

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80066(a)(12)(B)1
Personnel Records
(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: (12) For employees that are required to be fingerprinted pursuant to Section 80019: (B) Documentation of either a criminal record clearance or exemption as required by Section 80019(e). 1. For Certified Administrators, a copy of their current and valid Administrator Certification meets this requirement.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review the licensee did not comply with the section cited above by not having documentation of Staff #1 (S1) and Staff #2 (S2) criminal record clearance and not having record of Administrator's certification status for review, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/08/2024
Plan of Correction
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The Licensee/Administrator shall submit to the Licensing Agency documentation of the above by POC due date.
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:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2024


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 02/16/2024 05:17 PM - It Cannot Be Edited


Created By: Magda Malcore On 02/16/2024 at 04:21 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: BIG HEARTS LOMAS VERDES, INC.
FACILITY NUMBER: 361880877

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)
Personnel Records
(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
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Based on LPA record review, the licensee did not comply with the section cited above by not having staff #1 and staff# 2 records at the facility for review; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/08/2024
Plan of Correction
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The Licensee/Admininstrator shall submit to the Licensing Agency documentation of staff's training, employee record, and health screening with tuberculosis results.
Section Cited
Personnel Records
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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2
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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:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2024


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 02/16/2024 05:17 PM - It Cannot Be Edited


Created By: Magda Malcore On 02/16/2024 at 04:21 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: BIG HEARTS LOMAS VERDES, INC.
FACILITY NUMBER: 361880877

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Admission Agreements
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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4
Type B
Section Cited
CCR
80070(b)(14)
Client Records
(b) Each record must contain information including, but not limited to, the following: (14) An account of the client's cash resources, personal property, and valuables entrusted as specified in Section 80026.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA file review, the licensee did not comply with the section cited above by not maintaining documentation of all client's cash transactions at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/08/2024
Plan of Correction
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The Licensee/Administrator shall submit to the Licensing Agency documentation of client's cash transactions for the months of January 2024 and February 2024.
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:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2024


LIC809 (FAS) - (06/04)
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