361881051-1-29-2024-56-AS-MMAE-CZY52M-20240129183433

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361881051
Report Date: 01/29/2024
Date Signed: 01/29/2024 06:34:46 PM

Document Has Been Signed on 01/29/2024 06:34 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	PACIFIC PINES		FACILITY NUMBER:	361881051
ADMINISTRATOR:	THRANE, NANCY		FACILITY TYPE:	740
ADDRESS:	217 N. GROVE ST.		TELEPHONE:	(909) 801-1911
CITY:	REDLANDS	STATE: CA	ZIP CODE:	92374
CAPACITY:	10	CENSUS: 9	DATE:	01/29/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Nancy Thrane, Administrator		TIME COMPLETED:	06:30 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) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Nancy Thrane, Administrator, and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) with a license capacity of (10) and a current census of (9) residents in care. The facility has a hospice waiver for (2) residents. LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: Physical Plant: Indoor and outdoor passageways are free of obstruction. The facility has no bodies of water accessible to residents in care. Outdoor shaded area is sufficient for resident activities; however the facility does not have an entirely enclosed outdoor leisure space and is currently providing care for persons with Dementia. Deficiency cited. The facility has sufficient lighting and is maintained at a comfortable temperature. Resident’s bathrooms were operating in safe and sanitary conditions. The hot water temperature in residents' bathrooms measured 106 degrees F. Resident’s bedrooms have sufficient lighting and furniture in good repair. Facility has carbon monoxide detectors and telephone service. The facility has sufficient linen, towels, and personal hygiene items for residents. The facility has posted in a common area, Community Care Licensing complaint poster, Ombudsman poster, theft and loss policy, "oxygen in use" signs, and emergency telephone numbers. Care & Supervision: Facility has 24-hour care staff. Staff working have criminal record clearances or exemptions through the Department.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024

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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PACIFIC PINES	FACILITY NUMBER: 361881051
	VISIT DATE: 01/29/2024

NARRATIVE

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Food Service: Facility has sufficient non-perishable and perishable food supply for residents in care. The refrigerator and freezer are operating in a healthful manner. Sharps, pesticides and other cleaning solutions were kept locked and stored away from food areas.
Record Review: Review of (4) staff files reveal, the facility did not maintain record of staff #1 (S1) and staff #2 (S2) required job training on file. Deficiency cited. (4) resident files reviewed were observed to be complete. The last fire safety drill was conducted on 12/13/23. Administrator’s certification expires on 2/9/2024. Facility's liability insurance expires on 4/22/24.

Medical Related Services: All medication is centrally stored and kept locked in medication room.

Based on observations and record review, deficiencies are being 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 with Appeal Rights were provided to the Administrator at the conclusion of the visit.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/29/2024 06:34 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: PACIFIC PINES	FACILITY NUMBER: 361881051
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(h)

Outdoor faciilty space use for resident recreation and leisure shall be completely enclosed by a fence...to protect the safety of the residents. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observations, the licensee did not comply with the section cited above by the facility does not have a entirely enclosed outdoor leisure space and is currently providing care for persons with Dementia, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/15/2024
	Plan of Correction
1 2 3 4	The Licensee shall submit to the Licensing Agency proof of enclosed outdoor area space for residents with Dementia.

Type B

Section Cited

CCR

87412(c)(1)(A)(B)

(c) Licensees shall maintain in the personnel records verification of required staff training and orientation.(1) The following staff training and orientation shall be documented: (A) For staff who assist with personal activities of daily living, there shall be documentation of at least ten hours of initial training within the first four weeks of employment, and at least four hours of training annually thereafter...(B) For staff who provide direct care to residents with dementia in a facility...the licensee shall document the following:1. The orientation received as specified in Section 87707(a)(1) 2. The in-service training received as specified in Section 87707(a)(2).This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observations, the licensee did not comply with the section cited above by not maintaining record of required training for staff #1 and staff 2; which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/15/2024
	Plan of Correction
1 2 3 4	The Licensee shall submit to the Licensing agency proof of training 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	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024

LIC809 (FAS) - (06/04)

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