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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880880
Report Date: 01/07/2025
Date Signed: 01/07/2025 01:34:59 PM

Document Has Been Signed on 01/07/2025 01:34 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:BIG HEARTS COLOMA, INC.FACILITY NUMBER:
361880880
ADMINISTRATOR/
DIRECTOR:		CHEA, PAULFACILITY TYPE:
735
ADDRESS:10686 COLOMA STTELEPHONE:
(909) 796-2722
CITY:LOMA LINDASTATE: CAZIP CODE:
92354
CAPACITY: 4CENSUS: 4DATE:
01/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:DSP Betty ArchuletaTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Sarina Ramirez conducted an unannounced required annual inspection to the facility. LPA met with Direct Staff Professional (DSP) Betty Archuleta and discussed the purpose of the visit.

The facility is an Adult Residential Facility (ARF), level 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 swimming pools or similar bodies of water. Facility's backyard is enclosed and gated. Indoor and outdoor activity areas are sufficient for clients in care. Client activities include community outings, day program participation, coloring/painting, bingo, and puzzles. The facility has sufficient lighting and is maintained at a comfortable temperature. Client bathrooms were operating in sanitary conditions. The hot water temperature measured at 109 and 112 degrees F. Client bedrooms have sufficient lighting and furniture in good repair. Facility has operating smoke detector and carbon monoxide alarms, laundry equipment and telephone service. The facility has sufficient linens and personal hygiene items for clients in care. The facility has posted in a common area emergency telephone numbers, facility license, menu, facility sketch, client roster, personnel report, activity schedule, and facility staff schedule.



Food Service: The facility has sufficient non-perishable and perishable food supply for clients in care. Sharps and chemicals were kept locked inaccessible to clients in care.
**** Continuation on LIC 809 – C****
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2025
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
Document Has Been Signed on 01/07/2025 01:34 PM - It Cannot Be Edited


Created By: Sarina Ramirez On 01/07/2025 at 12:59 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 COLOMA, INC.
FACILITY NUMBER: 361880880

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80026(j)
Safeguards for Cash Resources, Personal Property and Valuables
(j) Cash resources entrusted to the licensee and kept on the facility premises, shall be kept in a locked and secure location.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above by not leaving access to the caregivers which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/08/2025
Plan of Correction
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Administrator agreed to send LPA proof of P&I record for each client by POC due date
Type A
Section Cited
CCR
80066(e)
Personnel Records
(e) All personnel records shall be maintained at the facility site.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, interview, and record review, the licensee did not comply with the section cited above by not leaving caregiver access to staff files which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/08/2025
Plan of Correction
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Administrator agreed to provide proof of at least four staff files included but not limited to CPR certificates, CPI certificates, required trainings, health screening report, and TB results to LPA 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:Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/07/2025


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 01/07/2025 01:34 PM - It Cannot Be Edited


Created By: Sarina Ramirez On 01/07/2025 at 12:59 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 COLOMA, INC.
FACILITY NUMBER: 361880880

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80068(a)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above by not having admission agreements in client files which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/08/2025
Plan of Correction
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4
Administrator agreed to send proof of admission agreements for all four clients to LPA by POC due date
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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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:Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/07/2025


LIC809 (FAS) - (06/04)
Page: 3 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: BIG HEARTS COLOMA, INC.
FACILITY NUMBER: 361880880
VISIT DATE: 01/07/2025
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Care & Supervision: Facility has 24 hour care staff. Staff working have criminal record clearances.

Record Review: Review of (4) Client files were observed to be incomplete; Admission Agreements were missing and P&I cash were kept locked inaccessible for LPA review, deficiency will be issued. Staff files were kept locked inaccessible for LPA review, deficiency will be issued.

Medical Related Services: Client’s medications are labeled and centrally stored in a locked cabinet.

Based on observations and record review, deficiencies were 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 were provided to DSP Betty Archuleta.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025
LIC809 (FAS) - (06/04)
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