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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880879
Report Date: 02/22/2024
Date Signed: 02/22/2024 06:32:43 PM

Document Has Been Signed on 02/22/2024 06:32 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 COTTONWOOD, INC.FACILITY NUMBER:
361880879
ADMINISTRATOR:MANALAD, RONALDFACILITY TYPE:
735
ADDRESS:25556 COTTONWOOD RDTELEPHONE:
(909) 328-2446
CITY:LOMA LINDASTATE: CAZIP CODE:
92354
CAPACITY: 4CENSUS: 4DATE:
02/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Heidy SembelTIME COMPLETED:
06:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced required annual inspection to the facility. LPA met with Heidy Sembel and discussed the purpose of the visit.

The facility is an Adult Residential Facility (ARF). 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. The facility's backyard is enclosed with a self latching gate. Indoor and outdoor activity areas are sufficient for clients in care. Client activities include walks, community outings, games, reading books, 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 106 degrees F. Client bedrooms have sufficient lighting and furniture in good repair. The facility fireplace was kept covered and inaccessible to clients in care. The facility has operating carbon monoxide alarms, laundry equipment and telephone service. The facility's last fire drill was conducted on 2/1/24. The facility has sufficient linen and personal hygiene items for clients in care. The facility has posted in a common area: client registry, facility license, disaster evacuation plan and emergency telephone numbers. LPA observed uncovered trash bins used to discard waste in client bedrooms. Deficiency cited.


Food Service: The facility has sufficient non-perishable and perishable food supply for clients in care. The facility refrigerator and freezers were operating in a healthful manner. Sharps, cleaning solutions, and other toxins were kept locked and stored away from food areas.
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)
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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 COTTONWOOD, INC.
FACILITY NUMBER: 361880879
VISIT DATE: 02/22/2024
NARRATIVE
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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) resident files reveal, Client# 1 (C1) and Client# 2 (C2) did not have a current individual program plan (IPP) on file. C1's last IPP on file was dated 9/26/2019 and C2's last IPP on file was dated 9/30/2022. Deficiency cited.

Medical Related Services: All medication is centrally stored and kept in a locked cabinet; however, LPA observed medication that should have been discarded on 1/24 (according to label instructions) stored with Client #3 (C3's) current medications. Deficiency cited.

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 Sembel at the conclusion of the visit.
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 06:32 PM - It Cannot Be Edited


Created By: Magda Malcore On 02/22/2024 at 05:41 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 COTTONWOOD, INC.
FACILITY NUMBER: 361880879

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(f)(1)
Fixtures, Furniture, Equipment, and Supplies
(f) Solid waste shall be stored, located and disposed of in a manner that will not transmit communicable diseases or odors, create a nuisance, or provide a breeding place or food source for insects or rodents. (1) All containers, including movable bins, used for storage of solid wastes shall have tight-fitting covers kept on the containers; shall be in good repair, shall be leakproof and rodent-proof.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations, the licensee did not comply with the section cited above by uncovered trash bins use to discard waste were observed in client bedrooms, 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 proof of covered bins by POC due date.
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
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Based on LPA record review, the licensee did not comply with the section cited above by Client# 1 (C1) and Client# 2 (C2) did not have a current individual program plan (IPP) on file. C1's last IPP on file was dated 9/26/2019 and C2's last IPP on file was dated 9/30/2022, 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 proof of current IPP 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.
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 06:32 PM - It Cannot Be Edited


Created By: Magda Malcore On 02/22/2024 at 05:41 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 COTTONWOOD, INC.
FACILITY NUMBER: 361880879

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(k)(3)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (3) All medications shall be labeled and maintained in compliance with label instructions and state and federal laws.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations, the licensee did not comply with the section cited above by LPA observed medication that should have been discarded on 1/24 (according to label instructions) stored with Client #3 (C3's) current medications; 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 read and submit a statement of understanding of the cited regulation to the Licensing Agency 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: 02/22/2024
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)
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