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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880880
Report Date: 02/27/2024
Date Signed: 02/27/2024 11:42:47 AM

Document Has Been Signed on 02/27/2024 11:42 AM - 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 COLOMA, INC.FACILITY NUMBER:
361880880
ADMINISTRATOR:CHEA, PAULFACILITY TYPE:
735
ADDRESS:10686 COLOMA STTELEPHONE:
(909) 796-2722
CITY:LOMA LINDASTATE: CAZIP CODE:
92354
CAPACITY: 4CENSUS: 4DATE:
02/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Paul Chea - AdministratorTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced required annual inspection to the facility. LPA met with Administrator, Paul Chea 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). During the visit, one client was present and three (3) clients were attending Day Program. 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, board games, watching movies, 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 106 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, client personal rights, and disaster evacuation plan and emergency telephone numbers.


Food Service: Facility has sufficient non-perishable and perishable food supply for clients in care. Sharps, cleaning solutions and other toxins were kept locked. The facility has sufficient cups, plates, and utensils for client use.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/27/2024
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 COLOMA, INC.
FACILITY NUMBER: 361880880
VISIT DATE: 02/27/2024
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Care & Supervision: Facility has 24 hour care staff.

Record Review: Review all client files were observed to be complete. The Administrator's certification expires on 7/21/2025. Review of five (5) staff files reveals, the facility did not maintain on file, record of Staff #1 (S1's) tuberculosis results. Deficiency Cited.

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

Based on observations and record review, a deficiency is 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 the Administrator at the conclusion of the visit.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/27/2024 11:42 AM - It Cannot Be Edited


Created By: Magda Malcore On 02/27/2024 at 10:57 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 COLOMA, INC.
FACILITY NUMBER: 361880880

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Personnel Records
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Type B
Section Cited
CCR
80066(a)(11)
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: (11) Tuberculosis test documents as specified in Section 80065(g).

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 facility did not maintain on file record of Staff #1 (S1's) tuberculosis results; 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 Licensing Agency documentation of S1's tuberculosis results 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: 02/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2024


LIC809 (FAS) - (06/04)
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