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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881134
Report Date: 10/27/2023
Date Signed: 10/27/2023 04:22:43 PM


Document Has Been Signed on 10/27/2023 04:22 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:ALLARA SENIOR LIVINGFACILITY NUMBER:
361881134
ADMINISTRATOR:HEFNER, LEEANNFACILITY TYPE:
740
ADDRESS:9417 19TH STREETTELEPHONE:
(909) 736-1900
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91701
CAPACITY:120CENSUS: 26DATE:
10/27/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Helen Jaquez, Business Office ManagerTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at Allara Senior Living Facility, Residential Care Facility for the Elderly to conduct a Health and Safety Case Management Visit. This Case Management visit is in response to a Special/Unusual Incident Report, (SIR) called into the Community Care Licensing Office by voicemail on 10/26/23. LPA met with Business Office Manager, Helen Jaquez, introduced self and stated purpose of the visit; which is to gather more information about the incident and surrounding events.

The incident reported occurred 10/26/23 at approximately 5:30pm, R1 departed the facility through an unlocked door of the Memory Care Unit. R1 walked to the main street (19th Street) was witnessed by a bystander who contacted the Police. The Police transported R1 to the station, contacted the facility to confirm, and returned the resident back to the facility.

Today's visit consisted of a walk through of the Memory Care Unit, observation of the door and route R1 used to depart facility, staff interviews and record reviews.

According to staff interviews, on 10/26/23 during the 2pm to 10pm shift; there were 4 staff members assigned to the floor. At approximately 5:30pm, 2 staff left the floor for break. Leaving 2 staff members on the floor. There were no witnesses to the resident's departure. LPA was informed that the memory care unit is a secure unit. When the door is opened an alarm is supposed to sound, but the door alarm failed. Its unknown how often the doors and alarms are checked. At this time, parts have been purchased to fix the alarm and staff is in the process of contacting the alarm company to schedule an appointment. Until the door, lock and alarm can be fixed, a staff member has been stationed to the door. Resident checks have been increased to provide rounds or checks every 30 minutes. R1 was assessed upon the return to the facility. According to staff, R1 had no apparent injuries to her person.

Please see LIC809-C
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
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)
Page: 1 of 3


Document Has Been Signed on 10/27/2023 04:22 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: ALLARA SENIOR LIVING
FACILITY NUMBER: 361881134

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/30/2023
Section Cited
CCR
80078(a)

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80078 Responsibility for Providing Care and Supervision
(a) The licensee shall provide care and supervision as necessary to meet the client's needs.
This requirement is not met as evidenced by:
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During the visit, Vortex staff was dispatched to fix the door before the end of the day. Staff. Caregivers/Staff has been increase from 2 caregivers to 3 caregivers to provide additonal support for the memory care unit on going.
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Based on interviews and record reviews, the Administrator failed to ensure the resident had assistance/supervision before leaving the facility on 10/26/23. Additionally, not ensuring the unit was secure to prevent R1 from departing facility; which posed an immediate Health, Safety and Personal Rights risk to persons in care.
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Administrator agrees complete a statement of understanding by way of a LIC9098 and submit this LIC9098 to the Community Care Licensing Office by 10/30/23

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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: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
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 3


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: ALLARA SENIOR LIVING
FACILITY NUMBER: 361881134
VISIT DATE: 10/27/2023
NARRATIVE
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At approximately 2:30pm LPA was provided a copy of R1's Physician's Report. LPA observed that the document was missing a signature of the R1's representative. The report indicates R1 cannot leave the facility unassisted. Mental condition includes wandering.

Based on observations, record reviews and staff interviews deficiencies will be cited to address the above mentioned concerns.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
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
LIC809 (FAS) - (06/04)
Page: 3 of 3