361880991-11-15-2023-56-AS-MBRN-CXLUZA-20231115150114

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361880991
Report Date: 11/15/2023
Date Signed: 11/15/2023 03:01:23 PM

Document Has Been Signed on 11/15/2023 03:01 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME:	BEST CARE GUEST HOME		FACILITY NUMBER:	361880991
ADMINISTRATOR:	GARCIA, RICHIE		FACILITY TYPE:	740
ADDRESS:	817 S OAKS AVENUE		TELEPHONE:	(909) 638-8871
CITY:	ONTARIO	STATE: CA	ZIP CODE:	91762
CAPACITY:	14	CENSUS: 12	DATE:	11/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Administrator Richie Garcia		TIME COMPLETED:	03:10 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 11/15/2023 at 08:45 AM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Brown met with Administrator Richie Garcia, and was granted entry to the facility. At the time of the visit there were three (3) staff present, and three (3) residents present. The facility is a eleven (11) bedroom, eight (8) bathroom home with a kitchen/dining area, living room. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of fourteen (14) non-ambulatory residents and the current census is twelve (12) residents. LPA Brown was accompanied by Administrator Garcia to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. Resident #1 (R1) did not have lamp in their bedroom. The shower in Room #2, Room #3 and Room #8 did not have a non-slip mat on the shower floor. During the tour of the facility, LPA Brown observed that Resident #12 has a half bedrail and no written order from R12's physician indicating the need for the postural support maintained in R12's facility record. Also, LPA Brown observed the side gate secured and locked with padlock. This poses an immediate and potential health, safety risk to residents in care. Deficiencies will be issued for the lamp and the non-slip mat and for locking/securing the side gate with padlock. LPA observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperatures in the bathroom to be at 110 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, labor laws, and the disaster plan were posted in a common area. *Continuation in LIC809C *

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

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 11/15/2023 03:01 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: BEST CARE GUEST HOME	FACILITY NUMBER: 361880991
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(5)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. 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 by pre-pouring 12 out of 12 residents whole day medication in a small container which poses an immediate health, safety or personal rights risk to residents in care.
	POC Due Date: 11/16/2023
	Plan of Correction
1 2 3 4	The Licensee stated to train all staff on CCR 87465(h)(5) and submit proof of Staff Training Log to LPA Brown at plan of correction (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: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/15/2023 03:01 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: BEST CARE GUEST HOME	FACILITY NUMBER: 361880991
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(d)

Maintenance and Operation

(d) There shall be lamps or light appropriate for the use of each room and sufficient to ensure the comfort and safety of all persons in the facility. 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 by not having a lamp in Resident #1 (R1) bedroom which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/24/2023
	Plan of Correction
1 2 3 4	The Licensee stated to purchase lamp for R1's bedroom and submit proof to LPA Brown at POC due date.

Type B

Section Cited

CCR

87303(e)(5)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers. 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 by not having non-skid mats or strips in Room #2, Room #3 and Room #8 which poses a potential health, safety or personal rights risk to residents in care.
	POC Due Date: 11/24/2023
	Plan of Correction
1 2 3 4	The Licensee stated to purchase non-skid mats or strips for Room #2, Room #3 and Room #8 and submit prrof to LPA Brown at 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: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: BEST CARE GUEST HOME	FACILITY NUMBER: 361880991
	VISIT DATE: 11/15/2023

NARRATIVE

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Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. There is a cabinet with the majority of the resident’s medications locked in the medication room. However, LPA Brown found residents medications pre-poured in a small container for the day, up to bedtime medication for each resident at the facility. The facility will be issued a deficiency for medication issue.

Food Service: Seven (7) days non-perishable and three (3) days perishable food supply observed at the facility.

Care & Supervision: The facility has an administrator present in the facility. LPA Brown observed sufficient number of staff to provide care and supervision to the residents in care.

Record Review: LPA reviewed six (6) resident files for admission agreements, updated physician reports, and needs and services plans. The files were complete with updated physician’s reports, admissions agreements, and preadmissions appraisals. LPA reviewed six (6) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA found that six (6) of the six (6) staff have CPR training, staff are properly trained in medication, dementia care, and basic training required for an RCFE. Medications/Medication Administration Record (MAR) were audited and appeared to be dispensed appropriately by staff members.

Based on the observations made during today’s visit, four (4) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809), LIC809D forms, and Appeal Rights were discussed and provided to Administrator Richie Garcia.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/15/2023 03:01 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: BEST CARE GUEST HOME	FACILITY NUMBER: 361880991
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87203

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshall for the protection of life and property against fire and panic. 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 by securing the side gate in the backyard with a pad lock which poses potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/16/2023
	Plan of Correction
1 2 3 4	The Licensee unlocked/removed the pad lock that secured the side gate of the facility during the visit. POC Cleared. Licensee shall keep the side gate secured but not locked in any capacity. The LIcensee stated to train all staff on CCR 87203 and submit proof of Training Log to LPA Brown at 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: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

LIC809 (FAS) - (06/04)

Page: 5 of 6

Document Has Been Signed on 11/15/2023 03:01 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: BEST CARE GUEST HOME	FACILITY NUMBER: 361880991
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87608(a)(3)

87608 Postural Supports (a) Based on the individuals preadmission appraisal....(3) A written order from a physician indicating the need for the postural support shall be maintained in the residents record. The licensing agency... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview andrecord review, the licensee did not comply with the section cited above by having Resident #12 (R12) half bed rail with no written order from R12's physician indicating the need for the postural support maintained in R12's facility record which poses a potential health, safety or personal rights risk to residents in care.
	POC Due Date: 11/24/2023
	Plan of Correction
1 2 3 4	The Licensee stated to submit written order from R12's physician indicating the need for the postural support and submit letter to Community Care Licensing Division (CCLD) requesting approval for R12's half bedrail at the facility by plan of correction (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: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

LIC809 (FAS) - (06/04)

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