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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881134
Report Date: 11/30/2023
Date Signed: 11/30/2023 01:37:50 PM


Document Has Been Signed on 11/30/2023 01:37 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: 40DATE:
11/30/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Gabriel Salazar, Resident Care DirectorTIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst, Amber Coleman, (LPA) made an unannounced complaint visit for complaint 56-AS-20231121172525. It was during this visit, LPA’s observed deficiencies not related to the complaint allegations.

LPA reviewed resident records and observed that three resident records contained Physician's Reports (LIC602) that were outdated. Staff interviews revealed that the facility had not had the resident's Physician's Reports completed with in the regulated time frame. LPA and staff worked together to coordinate getting the residents Physician's Reports completed. Resident Care Director agreed to work with the residents, their families and primary care physician's to have the Physician's Report completed.

Based on record reviews, a deficiency is being cited per Title 22, California Code of Regulations. A copy of this report was read/reviewed with Facility Representative; signature acknowledges understanding and receipt of report and attachments.

SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023
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 11/30/2023 01:37 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: 11/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/15/2023
Section Cited
CCR
80069(1)(a)

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80069 Client Medical Assessment The assessment shall be performed by a licensed physician or designee, who is also a licensed professional, and the assessment shall not be more than one year old when obtained.
This requirement is not met as evidenced by:
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Administrator agrees to work with the residents, their families and primary care physicians to obtain a current medical assessment. Administrator agrees to submit verification that the Physician's Reports were completed to the Community Care Licensing Office within the following 14 business days.
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Based on a review of records, Administrator did not ensure 3 resident's files contained current (annual) Physician's Peports within the regulated timeframe which poses a potential Health, Safety, and/or personal rights risk to persons 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: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023
LIC809 (FAS) - (06/04)
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