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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881005
Report Date: 10/27/2023
Date Signed: 10/27/2023 12:12:47 PM


Document Has Been Signed on 10/27/2023 12:12 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:A AND E LOVING SENIOR HOME CARE, INC.FACILITY NUMBER:
361881005
ADMINISTRATOR:BERNARDO, RUSSELLFACILITY TYPE:
740
ADDRESS:14931 OAKSPRING DRIVETELEPHONE:
(909) 320-7888
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY:6CENSUS: 4DATE:
10/27/2023
TYPE OF VISIT:Case Management - DeficienciesANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Licensee/Administrator Evafe Green - Sosnovsky and Administrator Russel BernardoTIME COMPLETED:
12:00 PM
NARRATIVE
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On 10/27/2023 at 11:00 AM, Licensing Program Analyst (LPA) Melody Brown met with Licensee/Administrator Evafe Green - Sosnovsky and Administrator Russel Bernardo at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office to initiate a Case Management Office Visit. LPA Brown explained the purpose of the requested Office Visit. The investigation consisted of interviews and a review of pertinent documentation.

On 10/23/2023, LPA Brown received Personnel Report Summary (LIC500) from Administrator Russel Bernardo and LPA Brown observed that no staff are scheduled to work on a night (NOC) shift. LPA Brown immediately address the issue with S2. LPA Brown explained to Administrator Bernardo that per Title 22 Regulation 87705 Care of Persons with dementia, their facility must have at least one night staff person awake and on duty if any resident with Dementia is determined through a pre-admission appraisal, reappraisal or observation to require awake night supervision. Interview with Staff #2 (S2) during the visit on 10/23/2023 indicated that the facility have two (2) residents with dementia and two (2) residents with mild cognitive impairment. S2 verbalized understanding during the visit on 10/23/2023 and updated the facility's LIC500 showing S2 as staff coverage on night (NOC) shift. On 10/27/2023, LPA Brown informed Licensee/Administrator Evafe Green - Sosnovsky and Administrator Russel Bernardo that deficiency will be issued as this pose immediate health, safety and personal rights risk to residents in care.

Moreover, per review of R1's Physician Report (LIC602), LPA Brown observed that the facility failed to complete the required annual medical assessment, reappraisal and reassessment done for R1's dementia care needs. LPA Brown informed Staff #1 (S1) and S2 that deficiency will be issued as this pose potential health, safety and personal rights risk to residents in care.

An exit interview was conducted where this report LIC809, 809D and Appeal Rights were discussed and provided to Licensee/Administrator Evafe Green - Sosnovsky and Administrator Russel Bernardo.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2023
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 10/27/2023 12:12 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: A AND E LOVING SENIOR HOME CARE, INC.
FACILITY NUMBER: 361881005

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/28/2023
Section Cited
CCR
87705(4)(A)

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87705 Care of Persons with Dementia (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. (A) In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal... This requirement is not met as evidenced by:

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The Licensee stated to train all staff on CCR 87705(4)(A) and submit proof of Training Log to LPA Brown at Plan of Correction (POC) due date.
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Based on interviews & records review, it was found that Licensee did not ensure there's a staff scheduled to work night (NOC) shift for night supervision to residents with dementia which pose immediate health, safety and personal rights risk to residents in care.
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Type B
11/06/2023
Section Cited
CCR87705(5)

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87705 Care of Persons with Dementia (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of...This requirement is not met as evidenced by:
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The Licensee stated to train all staff on CCR 87705(5) and submit proof of Training Log to LPA Brown at POC due date.
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Based on interviews & records review, the Licensee did not comply with the section cited above by failing to complete the required annual medical assessment, reappraisal and reassessment done for R1's dementia care needs which pose potential health, safety and personal rights risks to resident in care.
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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 MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2