361881272-6-15-2023-56-AS-VCHN-CSTPRG-20230615113244

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361881272
Report Date: 06/15/2023
Date Signed: 06/15/2023 11:35:52 AM

Document Has Been Signed on 06/15/2023 11:35 AM - 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:	ST. CLARE FAMILY HOME		FACILITY NUMBER:	361881272
ADMINISTRATOR:	TAN, CARLITO		FACILITY TYPE:	735
ADDRESS:	2608 GARFIELD AVENUE		TELEPHONE:	(909) 472-1767
CITY:	ONTARIO	STATE: CA	ZIP CODE:	91761
CAPACITY: 4		CENSUS: 4	DATE:	06/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Antonio Sanchez		TIME COMPLETED:	11:50 AM

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) Victoria Chitgian arrived unannounced to the facility for a required annual inspection. Facility is an Adult Residential Facility licensed for two (2) ambulatory and two (2) non-ambulatory clients. LPA met with Administrator Antonio Sanchez. At the time of the visit, one client was present at the facility. LPA toured the facility inside and outside. Outdoor and indoor passageways were kept free of obstruction. The facility has charged fire extinguishers, operating fire alarm systems, and carbon monoxide detectors. LPA toured the kitchen. Food was stored in a safe and healthful manner. The facility had a two (2) day supply of perishable food items and seven (7) day supply of nonperishable food items. LPA toured the client bedrooms. The client bedrooms had the required furniture and functional lighting. The facility had a supply of additional linen and extra hygiene items for the clients. The facility had a complete first aid kit available and the last disaster drill was conducted on 6/1/2023. Cleaning supplies, medications, and sharps were kept locked and inaccessible to the clients. Cleaning supplies were stored in the storage and laundry areas. Centrally stored medications were kept in a safe and locked cabinet. LPA toured the client bathrooms. The hot water temperature in the client bathroom was measured 106 degrees Fahrenheit. LPA observed the toilet in bathroom #1 was not functioning, and in need of repair. Administrator stated having made contact with a few contractors to begin the repair. Administrator provided the LPA with messages for the repair inquiry. Technical Assistance issued. The outside of the facility had a shaded area with a table and chairs. The facility does not have a pool or bodies of water. LPA reviewed staff and client files. LPA observed the Administrator did not have the required HIV and TB training. Deficiency issued. Client files had the required documentation including an admission's agreement, updated physician's reports, and appraisal/needs & services plans. LPA reviewed medications. Medications were dispensed appropriately according to the physician's orders. Licensee has secured each consumer’s personal property and resources. Sufficient staff are employed and present in the facility to meet the needs of the consumers in care. LPA observed the emergency supplies in the garage.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Victoria Chitgian
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

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 06/15/2023 11:35 AM - It Cannot Be Edited

Created By: Victoria Chitgian On 06/15/2023 at 11:09 AM

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
RIVERSIDE, CA 92507

FACILITY NAME: ST. CLARE FAMILY HOME	FACILITY NUMBER: 361881272
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85064(k)

Administrator Qualifications and Duties

(k) Within six months of becoming an administrator, the individual shall receive training on HIV and TB required by Health and Safety Code Section 1562.5. Thereafter, the administrator shall receive updated training every two years. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above as the Administrator did not complete the required course above, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/14/2023
	Plan of Correction
1 2 3 4	Administrator will enroll in a HIV/TB training course and submit confirmation to CCLD by POC due date above.

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:

Efren Malagon

LICENSING EVALUATOR NAME:

Victoria Chitgian

LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

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: ST. CLARE FAMILY HOME	FACILITY NUMBER: 361881272
	VISIT DATE: 06/15/2023

NARRATIVE

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Required signs and postings were observed in a common area, including the visitation policy and LIC 610D. LPA observed the floor plan posted did not indicate the evacuation path and assembly point. Administrator stated to make the update to the sketch. Technical Assistance issued.

One deficiency was issued during this visit. Two (2) technical assistance issued. An exit interview was conducted where this report, LIC 809, LIC 809-D, and appeal rights was provided to the Administrator Antonio Sanchez, at the end of the visit.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Victoria Chitgian
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

LIC809 (FAS) - (06/04)

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