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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881069
Report Date: 04/09/2024
Date Signed: 04/09/2024 01:58:06 PM

Document Has Been Signed on 04/09/2024 01:58 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:NABIH'S CARE HOMEFACILITY NUMBER:
361881069
ADMINISTRATOR/
DIRECTOR:		DINEROS, OLIVERFACILITY TYPE:
735
ADDRESS:407 W. SPRUCE STTELEPHONE:
(909) 996-2108
CITY:ONTARIOSTATE: CAZIP CODE:
91762
CAPACITY: 4CENSUS: 2DATE:
04/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:55 AM
MET WITH:Administrator Dominador Bartolata IIITIME VISIT/
INSPECTION COMPLETED:
02:10 PM
NARRATIVE
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On 04/09/2024 at 10:55 AM, Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility to conduct the required comprehensive annual inspection to the facility. LPA Brown met with a staff. Administrator Dominador Bartolata III was contacted and arrived during the visit. LPA Brown explained the purpose of today's visit to Administrator Dominador Bartolata III.

The facility has 4 bedrooms, 2 bathrooms, kitchen, dining room, living room, attached garage, and backyard. The facility is vendorized by Inland Regional Center. LPA Brown completed a walkthrough of the facility, review of records, P & I audit and medications audit.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD), LPA Brown observed two (2) clients during the visit. One (1) client's out in the community. There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 74 degrees Fahrenheit. LPA Brown inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs, and sufficient lighting. LPA Brown inspected client bathrooms; bathrooms were clean, and appliances were found functional. Water temperatures tested at 111 degrees Fahrenheit. The facility is equipped with operational smoke detectors, charged fire extinguisher but LPA Brown observed one (1) carbon monoxide detector not working. Deficiency will be issued. Administrator Bartolata III repaired the carbon monoxide detector during the visit. LPA Brown observed first aid book but incomplete first aid kit. Deficiency will be issued. Administrator Bartolata III brought a complete set of first aid kit during the visit. In addition, LPA Brown observed no night lights maintained in hallways and passages to non-private bathrooms. Deficiency will be issued.

*** Continuation in LIC809C ***
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/09/2024
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: NABIH'S CARE HOME
FACILITY NUMBER: 361881069
VISIT DATE: 04/09/2024
NARRATIVE
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Posters such as; the personal rights, CCLD complaint poster, emergency disaster plan were posted in a common area. Sharps and client medications were kept in secure cabinets inaccessible to clients. The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility.

Yards/Outside: One shaded patio, two (2) side gate with self-latching handle on the left and right side of the house that leads into the backyard, attached two (2) car garage observed. All outdoor pathways were free of obstructions.

Food Service: LPA observed two (2) day(s) supply of perishable food and seven (7) day(s) supply of non-perishables food and snacks. Dishes, cups, and utensils were stored properly.


Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPA Brown observed no Infection Control Plan at the facility. Deficiency will be issued. LPA Brown reviewed client files for admission agreements, medical assessments/physician reports, needs and Individual Services Plan (IPP). LPA Brown observed that Client #2 (C2) does not have Admission Agreement on C2 file. Deficiency will be issued. LPA Brown also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with Tuberculosis (TB) test result. LPA Brown observed Staff #1 (S1) and Staff #2 (S2) with Criminal Record Clearance but S1 and S2 were not associated to the facility due to S1's and S2's criminal record clearance was not transferred to the facility. Deficiency will be issued and civil penalty of $500.00 per individual will be assessed during the visit today, 04/09/2024l and will continue to be assessed of $100.00 per day per citation until corrected.

LPA Brown audited two(2) clients medications and no issues were observed. LPA Brown audited two (2) client's P&I and no issues were observed.

Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC421BG, LIC9102 and Appeal Rights were discussed and copies were provided to Administrator Dominador Bartolata III.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024
LIC809 (FAS) - (06/04)
Page: 2 of 17
Document Has Been Signed on 04/09/2024 01:58 PM - It Cannot Be Edited


Created By: Melody Brown On 04/09/2024 at 01:21 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: NABIH'S CARE HOME
FACILITY NUMBER: 361881069

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1503.2
General Provisions
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by having a non-working carbon monoxide detector at the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/10/2024
Plan of Correction
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Administrator Bartolata III repaired the not working carbon monoxide during the visit on 04/09/2024. Plan of Correction (POC) cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 04/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2024


LIC809 (FAS) - (06/04)
Page: 3 of 17
Document Has Been Signed on 04/09/2024 01:58 PM - It Cannot Be Edited


Created By: Melody Brown On 04/09/2024 at 01:21 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: NABIH'S CARE HOME
FACILITY NUMBER: 361881069

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not developing the required Infection Control Plan for the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/19/2024
Plan of Correction
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Licensee stated to submit the required Infection Control Plan to LPA Brown at Plan of Correction (POC) due date.
Type B
Section Cited
CCR
85088(e)(2)
Fixtures, Furniture, Equipment, and Supplies
(e) Emergency lighting, which shall include at a minimum working flashlights or other battery-powered lighting, shall be maintained and readily available in areas accessible to clients and staff. (2) Night lights shall be maintained in hallways and passages to nonprivate bathrooms.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not having the required night lights maintained in hallways and passages to nonprivate bathrooms which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/19/2024
Plan of Correction
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Licensee stated to submit proof of nightlights maintained in hallways and passages to nonprivate bathrooms to LPA Brown at Plan of Correction (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
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 04/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2024


LIC809 (FAS) - (06/04)
Page: 4 of 17
Document Has Been Signed on 04/09/2024 01:58 PM - It Cannot Be Edited


Created By: Melody Brown On 04/09/2024 at 01:21 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: NABIH'S CARE HOME
FACILITY NUMBER: 361881069

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80019(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 80019(f) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not transferring Staff #1 (S1) and Staff #2 (S2) criminal record clearance to the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/26/2024
Plan of Correction
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Licensee stated to transfer S1 and S2 criminal record clearance to the facility and submit proof to LPA Brown on Plan of Correction (POC) due date.
Type B
Section Cited
CCR
80068(a)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not having Client #2 Admission Agreement maintained in C2 file poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/19/2024
Plan of Correction
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Licensee stated to submit a copy of C2 Admission Agreement to LPA Brown on Plan of Correction (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
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 04/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2024


LIC809 (FAS) - (06/04)
Page: 5 of 17
Document Has Been Signed on 04/09/2024 01:58 PM - It Cannot Be Edited


Created By: Melody Brown On 04/09/2024 at 01:21 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: NABIH'S CARE HOME
FACILITY NUMBER: 361881069

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(g)
Health-Related Services
(g) If the facility has no medical unit on the grounds, first aid supplies shall be maintained and be readily available in a central location in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not having a complete set of first aid supplies maintained at the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/19/2024
Plan of Correction
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Licensee brought a complete set of First Aid Supplies for the facility during the visit. Plan of Correction (POC) cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 04/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2024


LIC809 (FAS) - (06/04)
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