361880901-7-18-2023-56-AS-MECA-CTUVDK-20230718162052

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361880901
Report Date: 07/18/2023
Date Signed: 07/18/2023 04:21:11 PM

Document Has Been Signed on 07/18/2023 04:21 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:	B SMITH BOARD AND CARE		FACILITY NUMBER:	361880901
ADMINISTRATOR:	SMITH, BRITTNEY		FACILITY TYPE:	740
ADDRESS:	10583 PORTLAND AVE		TELEPHONE:	(909) 244-4280
CITY:	HESPERIA	STATE: CA	ZIP CODE:	92345
CAPACITY:	4	CENSUS: 3	DATE:	07/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:22 AM
MET WITH:	Brittney Smith-Licensee		TIME COMPLETED:	04:25 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	On 07/18/23 at 8:22 AM, Licensing Program Analyst (LPA) Michelle Echeverria arrived at the facility unannounced to conduct a required Annual visit. LPA was greeted and granted entrance by Licensee, Brittney Smith. LPA introduced self and stated the purpose of the visit. LPA observed that there are currently 3 residents in the facility. Licensee provided LPA with a tour of the facility. The facility has 3 bedrooms, 2 bathrooms, 1 staff office/bedroom, a kitchen, dining area, living room, attached garage, and backyard. LPA conducted a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is not clean, safe, and sanitary. LPA observed the living room with storage boxes, dirty floors and the back yard with dog feces and dog hair. Deficiency issued. The facility is not free of obstructions to indoor and outdoor passageways. LPA observed bricks, poles, building materials on side gate and driveway. Deficiency issued. The facility is maintained at a 76 degrees fahrenheit temperature. LPA inspected residents bedrooms; they are equipped with furniture such as: mattresses, night stands, storage space, and sufficient lighting. LPA noticed a malodor of urine in bedroom #3 with 2 residents inside laying down. Deficiency issued. LPA also observed cameras in residents room with audio confirmation per Licensee's statement. Deficiency issued. There is an adequate supply of linens and blankets stored in a closet in the main hallway of the residence. LPA inspected residents bathrooms; bathroom was clean and appliances were operating appropriately. LPA observed that the bathroom trash cans do not have a tight-fitting cover. Deficiency issued. LPA also observed PRN hemorrhoid ointment found in a cabinet beneath hallway bathroom sink. Technical violation issued. LPA tested the water temperature in the kitchen faucet, which tested at 110 degrees fahrenheit within regulation. The facility is equipped with operating fire extinguisher, smoke detectors and carbon monoxide alarm. Posters such as; the personal rights, CCL complaint poster, Ombudsman and the emergency disaster plan were posted in a common area.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023

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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Document Has Been Signed on 07/18/2023 04:21 PM - It Cannot Be Edited

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: B SMITH BOARD AND CARE	FACILITY NUMBER: 361880901
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87555(b)(26)

General Food Service Requirements

(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in maintainig 2 days of perishable foods which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/19/2023
	Plan of Correction
1 2 3 4	Licensee stated that she will go grocery shopping and submit proof to LPA via email by POC due date.

Type A

Section Cited

CCR

87705(f)(1)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in making knives and blades accessible which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/19/2023
	Plan of Correction
1 2 3 4	Licensee stated that she will lock knives and blades making it inaccessible to residents. Licensee stated that she will host a training with staff and submit proof to LPA via email 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: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/18/2023 04:21 PM - It Cannot Be Edited

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: B SMITH BOARD AND CARE	FACILITY NUMBER: 361880901
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in maintaining the facility clean, safe, sanitary and in good repair which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/25/2023
	Plan of Correction
1 2 3 4	Licensee stated that she will remove the storage boxes in the living room, clean and sanitize the floors along with the back yard that has dog feces and dog hair. Licensee stated that she will submit proof to LPA via email by POC due date.

Type B

Section Cited

CCR

87303(f)(4)

Maintenance and Operation

(f) Solid waste shall be stored and disposed of as follows: (4) Movable bins when used for storing or transporting solid wastes from the premises shall have tight-fitting covers on the containers; shall be in good repair; and shall be rodent-proof unless stored in a room or screened enclosure. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in providing tight-fitting covers in the bathrooms trash cans which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/25/2023
	Plan of Correction
1 2 3 4	Licensee stated that she will purchase tight-fitting containers for the bathrooms and submit proof to LPA via email 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: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/18/2023 04:21 PM - It Cannot Be Edited

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: B SMITH BOARD AND CARE	FACILITY NUMBER: 361880901
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(d)(6)

Personal Accommodations and Services

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in maintaining all outdoor and indoor passageways free of obstructions which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/25/2023
	Plan of Correction
1 2 3 4	Licensee stated that she will remove bricks, poles, building materials on side gate and driveway; and submit proof via email to LPA by POC due date.

Type B

Section Cited

CCR

87412(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
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in maintaining complete staff records which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/25/2023
	Plan of Correction
1 2 3 4	Licensee stated that she will review and complete staff records with First Aid/CPR certification and missing information. Licensee stated that she will submit proof to LPA via email 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: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/18/2023 04:21 PM - It Cannot Be Edited

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: B SMITH BOARD AND CARE	FACILITY NUMBER: 361880901
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(a)

Medical Assessment

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above in keeping residents file documentation of medical assessment which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/25/2023
	Plan of Correction
1 2 3 4	Licensee stated that she will obtain and keep in residents file documentation of a medical assessment. Licensee stated that she will submit proof to LPA via email by POC due date.

Type B

Section Cited

CCR

87468.2(a)

Additional Personal Rights of Residents in Privately Operated Facilities

(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in violating the residents personal rights by recording with visual and audio their privacy which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/25/2023
	Plan of Correction
1 2 3 4	Licensee stated that she will remove the cameras in the residents bedrooms. Licensee stated that she will submit proof to LPA via email 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: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/18/2023 04:21 PM - It Cannot Be Edited

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: B SMITH BOARD AND CARE	FACILITY NUMBER: 361880901
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(9)

General Food Service Requirements

(b) The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in protecting the safety, acceptability and nutritive values of food observation in food storage which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/25/2023
	Plan of Correction
1 2 3 4	Licensee stated that she will host a training with staff going over regulation 87555(b)(9) and submit proof to LPA via email by POC due date.

Type B

Section Cited

CCR

87555(b)(27)

General Food Service Requirements

(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in maintaining the refrigerator, pantry, stove and stove fans clean which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/25/2023
	Plan of Correction
1 2 3 4	Licensee stated that she will deep clean refrigerator, pantry, stove and stove fans. Licensee stated that she will train staff on regulation 87555(b)(27) and submit proof of cleaning and staff meeting via email 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: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/18/2023 04:21 PM - It Cannot Be Edited

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: B SMITH BOARD AND CARE	FACILITY NUMBER: 361880901
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87625(b)(3)

Managed Incontinence

(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in ensuring that the facility remains free of odors which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/25/2023
	Plan of Correction
1 2 3 4	Licensee stated that she will review regulation 87625(b)(3) with staff in a meeting. Licensee stated that will submit proof of meeting to LPA via email by POC due date.

Type B

Section Cited

CCR

87705(c)(3)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (3) In addition to the on-the-job training requirements in Section 87411(d), staff who provide direct care to residents with dementia shall receive the following training as appropriate for the job assigned and as evidenced by safe and effective job performance: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in providing appropriate on-the-job training for staff which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/25/2023
	Plan of Correction
1 2 3 4	Licensee stated that she will provide appropriate on-the-job training to staff and submit proof to LPA via email 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: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023

LIC809 (FAS) - (06/04)

Page: 7 of 9

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: B SMITH BOARD AND CARE	FACILITY NUMBER: 361880901
	VISIT DATE: 07/18/2023

NARRATIVE

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Cleaning supplies, and toxins were kept locked. LPA observed knives found in drawer and drying rack and a blade in a drawer made accessible to residents. Deficiency issued. There was a designated locked storage space for client/staff files, first aid kit and medication. The facility has a working phone. There are no pools, bodies of water, firearms or ammunition.

Yards/Outside: One shaded patio furniture for outdoor seating observed. Side gate with self-latching handle on the right side of the house that leads into the backyard. Dogs inside kennels also found in back yard.

Food Service: The facility has 7 days of non-perishable food supply and an insufficient supply of 2 days of perishable food. Deficiency issued. LPA observed 24 containers of expired Glucerna found in pantry since 02/01/23. Deficiency issued. LPA also observed the refrigerator, pantry, stove, and stove fan unsanitary and not clean. Deficiency issued. Dishes, cups, and utensils were stored properly.

Record Review: LPA reviewed the Administrator's file and 3 Staff files. Staff files are incomplete and missing First Aid/CPR certification. Deficiency issued. Staff training records missing. Deficiency issued. LPA also reviewed residents files and observed that the physicians report was missing. Deficiency issued.

Technical violation and deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102 and appeal rights were discussed and copies were provided to Licensee, Brittney Smith.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023

LIC809 (FAS) - (06/04)

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