361881000-10-21-2021-18-AS-ABUO-C7ZVNC-20211021163455

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361881000
Report Date: 10/21/2021
Date Signed: 10/21/2021 04:35:05 PM

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
RIVERSIDE, CA 92507

FACILITY NAME:	LOMBARDY SENIOR CARE, LLC		FACILITY NUMBER:	361881000
ADMINISTRATOR:	SOTERO CHANDLER RAMAS III		FACILITY TYPE:	740
ADDRESS:	4095 LOMBARDY AVE		TELEPHONE:	(661) 319-6671
CITY:	CHINO	STATE: CA	ZIP CODE:	91710
CAPACITY:	6	CENSUS: 6	DATE:	10/21/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Chandler Ramas - Administrator		TIME COMPLETED:	04:40 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	Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility for a required annual inspection, with emphasis on infection control. LPA met with staff Yolanda Bacani and Teodora Almagro. Administrator Chandler Ramas was phoned by staff and arrived during this visit. LPA toured the facility inside and out. The facility has no bodies of water. The facility has a charged fire extinguisher, operating smoke alarms, and carbon monoxide detector. Cleaning supplies, medications, and sharps were kept in a safe and locked place. Staff office is located in the garage, where cleaning supplies are kept as well. Medications were kept in a locked cabinet. Sharps were stored in a secured area. Resident bedrooms had the required furniture and sufficient lighting. Facility had a supply of additional linen and hygiene items. LPAs observed that the facility has a mitigation plan to mitigate the spread of COVID-19 in the facility. One central entry point and sign-in policy has been designated for universal entry screening. Routine symptom screening has been initiated at entry for all staff, residents, and visitors. Facility also documents daily temperature and COVID-19 symptom checks, and any change in condition for staff and residents. During the tour, LPA observed that Staff 1 (S1) has a criminal record clearances but was not associated to the facility. This poses an immediate health & safety risk to the residents in care. LPA were informed that S1 has worked at this facility since 10/15/21. A civil penalty of $500 was assessed on 10/21/21. A technical advisory was issued as LPA observed that the facility does not have at least a 30 day supply of personal protective equipment (PPE), specifically surgical masks/respirators. However, Administrator Ramas arrived with several boxes of surgical masks. Refer to LIC809D for deficiency cited. An exit interview was conducted where this report, LIC811, LIC809D, LIC421BG, and appeal rights were discussed and provided to administrator Ramas.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Anna Bueno	TELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021

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

FACILITY NAME: LOMBARDY SENIOR CARE, LLC	FACILITY NUMBER: 361881000
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/21/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(2)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview licensee did not comply with the section cited above as Staff 1 has a criminal record clearance but was not associated to the facility, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/22/2021
	Plan of Correction
1 2 3 4	Licensee shall submit to CCL proof of association of S1 no later than end of business day of POC date 10/22/2021.

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: Nedra Brown	TELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Anna Bueno	TELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021

LIC809 (FAS) - (06/04)

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