361881183-11-28-2023-56-AS-BWOT-CXZVV2-20231128154538

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361881183
Report Date: 11/28/2023
Date Signed: 11/28/2023 03:45:50 PM

Document Has Been Signed on 11/28/2023 03:45 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	MIRIAM'S HOMECARE		FACILITY NUMBER:	361881183
ADMINISTRATOR:	GAD, ENRICO		FACILITY TYPE:	740
ADDRESS:	1635 HAMPSHIRE RD		TELEPHONE:	(818) 912-0178
CITY:	SAN BERNARDINO	STATE: CA	ZIP CODE:	92404
CAPACITY:	6	CENSUS: 4	DATE:	11/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:23 AM
MET WITH:	Miriam Nauseda		TIME COMPLETED:	04:50 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) Anna Bueno & Bianca Wolcott arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff Miriam Nauseda and granted entry. LPA began inspection with introduction, visit purpose. Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. LPA observed fence in pool area with an unlocked gate. This poses a immediate health a safety risk to residents in care. LPAs notified staff Miriam Nauseda who immediately locked the pool gate. LPAs observed the facility to be clean and in good repair. The home is maintained at a comfortable temperature for the residents. Lighting is sufficient for safety and comfort. Water temperature measured 107-114 degrees F. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals under the sink. Fire extinguishers are charged, mounted and dated . All outdoor and indoor passageways are free of obstruction. A locked area is provided for medications and sharp objects. There is a telephone working at this location. The LIC 610E, emergency disaster plan is maintained. The facility has a current written definitive plan of operation. The facility is maintained in conformity with the regulations adopted by the state fire marshal. Personnel Records/Training/and Staffing-. LPA reviewed employee record for first aid certification, fingerprint clearance, personnel/job application, health screening and TB test results, criminal record statement, employee rights, training verification, and current administrator certification. Resident Records/Incident Reports/Personal Rights/Residents with Special Needs/Incidental Medical and Dental- LPA reviewed resident records. Three (4) records were reviewed. LPA reviewed for admission agreement, medical assessment and TB test results, consent forms, identification and emergency information, appraisal needs and service plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. The facility is meeting documentation requirements. Resident Rights are posted in the facility and a copy is signed on file.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Bianca Wolcott	TELEPHONE: (951) 248-0306
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023

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 11/28/2023 03:45 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MIRIAM'S HOMECARE	FACILITY NUMBER: 361881183
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(e)

Care of Persons with Dementia

(e) Swimming pools and other bodies of water shall be fenced and in compliance with state and local building codes. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs Bianca Wolcott & Anna Bueno observation, the licensee did not comply with the section cited above in having the fenced in pool gate locked. The pool gate was observed by LPAs as being unlocked. Which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/28/2023
	Plan of Correction
1 2 3 4	Licensee shall insure the pool gate is locked at all times. Miriam Nauseda, was notified by LPAs gate was unlocked and staff immediately locked it. This defenciey was immediately corrected during the visit.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Bianca Wolcott	TELEPHONE: (951) 248-0306
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/28/2023 03:45 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MIRIAM'S HOMECARE	FACILITY NUMBER: 361881183
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.605

Other Provisions

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation & phone interview with Adminstrator Enrico Gad the licensee did not comply with the section cited above as administrator Gad was not able to produce proff of current liability insurance coverage. Which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/12/2023
	Plan of Correction
1 2 3 4	Licensee will provide current liability insurance coverage to the Department no later than POC date.

Type B

Section Cited

CCR

87465(h)(4)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation & staff interview the licensee did not comply with the section cited as over the counter medications listed on the centralized medicine list. Lpas observed the same over the counter medicines in the Resident's medicine bin. Staff interview confirmed that the are administering the same over the counter medicines to the Resident. Which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/12/2023
	Plan of Correction
1 2 3 4	Licensee shall provide a physician's written order of approval to use the over the counter medications for Resident no late than end of POC 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: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Bianca Wolcott	TELEPHONE: (951) 248-0306
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023

LIC809 (FAS) - (06/04)

Page: 3 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MIRIAM'S HOMECARE	FACILITY NUMBER: 361881183
	VISIT DATE: 11/28/2023

NARRATIVE

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During the visit administrator Enrico Gad provided updated physicians reports for (3) residents. Resident Rights are posted in the facility and a copy is signed on file.

Food Service- LPAs were present during the lunch time meal. The meal is adequate to meet the nutritional needs of the residents. Food prep areas are clean and organized. Food supply meets the requirement of one week supply of nonperishable and 2-day supply of perishables food on hand.

LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. The facility has not exceeded its capacity limitation and the structure remains unchanged according to the approved floor plan. Smoke detectors and carbon monoxide detectors were tested and found to be operational. While reviewing medication and medication records, LPAs observed over the counter medications listed on the centralized medicine list.. This poses a potential health and safety risk to residents in care.

Two client interviews were conducted. One staff interview was conducted.

Based on the information received during this visit today, the following deficiency is being cited per Title 22, Division 6 of The California Code of Regulations.

This report was reviewed with and a copy provided to the facility representative. Appeal Rights were also provided at the time of the exit interview.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Bianca Wolcott	TELEPHONE: (951) 248-0306
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023

LIC809 (FAS) - (06/04)

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