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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530007
Report Date: 06/14/2023
Date Signed: 06/14/2023 10:18:20 AM


Document Has Been Signed on 06/14/2023 10:18 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:TRES MARIAS HOME CARE LLCFACILITY NUMBER:
365530007
ADMINISTRATOR:ALORO, MARIA NENITA N.FACILITY TYPE:
740
ADDRESS:749 W WINCHESTER DR.TELEPHONE:
(909) 874-4712
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY:6CENSUS: 5DATE:
06/14/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Maria Aloro, AdministratorTIME COMPLETED:
11:10 AM
NARRATIVE
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Tres Marias Home Care Facility to conduct a Case Management visit unrelated to the complaint. LPA was greeted by Administrator, Maria Aloro and discussed the purpose of the visit.

While reviewing resident files, LPA observed that a Physician's Report for a resident in care was out dated. LPA inquired about the outdated document. Administrator reported that the resident in care was on service with another agency and was not aware the document would still need to be kept up to date. LPA and Administrator discussed the document and regulation. Administrator expressed that she understood.

Based on observations and interviews made during today’s visit, one (1) deficiency is being cited per Title 22, Division 6, of the California Code of Regulations CCR). An exit interview was conducted and a copy of this report, LIC 809D, and Appeal Rights were given to the Licensee.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023
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 06/14/2023 10:18 AM - 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: TRES MARIAS HOME CARE LLC
FACILITY NUMBER: 365530007

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/14/2023
Section Cited
HSC
87458(a)

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87458 Medical Assessment - (a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year.

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Liensee Agrees to review the regulation for Medical Assessment and self certify that the regulation is understood by way of a LIC9098 Form. This form is to be completed, then submitted to Community Care Licensing Office within 7 days.
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This requirement was not met as evidenced by:
Based on observation and interviews, the licensee did not ensure resident in care had all documents as regulated which poses an potential Health and Safety 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: 06/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023
LIC809 (FAS) - (06/04)
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