<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880878
Report Date: 02/22/2024
Date Signed: 02/22/2024 12:45:31 PM

Document Has Been Signed on 02/22/2024 12:45 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 PARK, INC.FACILITY NUMBER:
361880878
ADMINISTRATOR:MAGLALANG, LOUELAFACILITY TYPE:
735
ADDRESS:25361 PARK AVETELEPHONE:
(909) 478-3738
CITY:LOMA LINDASTATE: CAZIP CODE:
92354
CAPACITY: 4CENSUS: 4DATE:
02/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Astrid LesiaselTIME COMPLETED:
12:45 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 (LPA) Magda Malcore conducted an unannounced required annual inspection to the facility. LPA met with Astrid Lesiasel and discussed the purpose of the visit.

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

Physical Plant & Operation: Indoor and outdoor passageways are free of obstruction. The facility has no outdoor bodies of water accessible to clients in care. Facility's backyard is enclosed and gated. Indoor and outdoor activity areas are sufficient for clients in care. Client activities include walks, arts and crafts, community outings and Day program participation. The facility has sufficient lighting and is maintained at a comfortable temperature. Client bathrooms were operating in safe and sanitary conditions. The hot water temperature in client bathrooms measure at 117 degrees F. Client bedrooms have sufficient lighting and furniture in good repair. Facility has operating carbon monoxide alarms, laundry equipment and telephone service. The facility has sufficient linen and personal hygiene items for clients in care. The facility has posted in a common area client registry, disaster evacuation plan and emergency telephone numbers.


Food Service: Facility has sufficient non-perishable and perishable food supply for clients in care. Pesticides and other cleaning solutions were kept locked and stored away from food areas. The facility's refrigerators' temperature measured at 40 degrees F; however, the freezer located in the garage temperature measured at 4 degrees F. Staff called their maintenance person but they were not available. Deficiency cited.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2024
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 4
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 PARK, INC.
FACILITY NUMBER: 361880878
VISIT DATE: 02/22/2024
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
26
27
28
29
30
31
32
Care & Supervision: Facility has 24 hour care staff. Staff working have criminal record clearances or exemptions through the Department.

Record Review: Review of (4) staff files were observed to be complete. Review of (4) client files reveal, Client# 1 (C1) did not have a current individual program plan (IPP) on file. C1's last IPP on file was conducted on 9/28/21. Deficiency cited.

Medical Related Services: All client medication is centrally stored and kept in a locked cabinet.

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

An exit interview was conducted where the Licensing reports were discussed and copies of the reports with Appeal Rights was provided to Lesiasel.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 02/22/2024 12:45 PM - It Cannot Be Edited


Created By: Magda Malcore On 02/22/2024 at 11:52 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
RIVERSIDE, CA 92507

FACILITY NAME: BIG HEARTS PARK, INC.
FACILITY NUMBER: 361880878

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85076(d)(2)
Food Service
(2) Freezers shall be large enough to accommodate required perishables and shall be maintained at a temperature of zero degrees F (-17.7 degrees C).

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 the freezer located in the garage temperature measured at 4 degrees F; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/23/2024
Plan of Correction
1
2
3
4
The Licensee/Administrator shall submit to the Licensing Agency proof of freezer is operating within regulation 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.
SUPERVISOR'S NAME:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 02/22/2024 12:45 PM - It Cannot Be Edited


Created By: Magda Malcore On 02/22/2024 at 11:52 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
RIVERSIDE, CA 92507

FACILITY NAME: BIG HEARTS PARK, INC.
FACILITY NUMBER: 361880878

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80068.3(a)
Modifications to Needs and Services Plan
(a) The licensee shall ensure that each client's written Needs and Services Plan is updated as often as necessary to assure its accuracy, but at least annually. These modifications shall be maintained in the client's file.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA record review, the licensee did not comply with the section cited above by Client# 1 (C1) did not have a current individual program plan (IPP) on file. C1's last IPP on file was conducted 9/28/21; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/08/2024
Plan of Correction
1
2
3
4
The Licensee/Administrator shall submit to the Licensing Agency proof of updated needs and service plan by POC due date.
Section Cited
Client Records
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.
SUPERVISOR'S NAME:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2024


LIC809 (FAS) - (06/04)
Page: 4 of 4