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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530012
Report Date: 12/05/2023
Date Signed: 12/05/2023 10:16:15 AM

Document Has Been Signed on 12/05/2023 10:16 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:HELPING HEARTS ACACIAFACILITY NUMBER:
365530012
ADMINISTRATOR:HAMPTON, CHRISTALFACILITY TYPE:
772
ADDRESS:1767 N ACACIA AVETELEPHONE:
(909) 292-8997
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY: 6CENSUS: 6DATE:
12/05/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Lori Secord, Program DirectorTIME COMPLETED:
10:20 AM
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Helping Hearts - Acacia unannounced to conduct a case management visit. This case management visit is in response to two incident reports submitted to the Community Care Licensing Office on 11/22/23 and 11/27/23. LPA met with Program Director, Lori Secord, introduced self and stated purpose of the visit.

The Special/Unusual Incident Report, (SIR) reported that on 11/22/23, R1 was not given all of R1's prescribed medications due to a medication capsule not popping out of the bubble and was not seen by staff until the following date. LPA unable to interview staff member. Program Director reported that the staff member was provided additional training in response and has had no further issues with assisting with medication management. The Nurse Hotline was contacted for advice. R1's physician was also contacted and informed. LPA reviewed staff file and verified medication management training.

On 11/27/23, it was reported that R2 was not given all of prescribed medications on 11/22/23. During staff interviews, LPA learned that the staff member involved was relatively new and not familiar with R2's behaviors. The missed dose of medication was realized on the following date. At this time, S2 was provided additional training in medication management, dealing with difficult personalities and power struggles. Program Director contacted the Nurse Hotline for advice and R2's primary care physician. LPA reviewed and verified medication management training for S2.

No deficiencies were cited during this visit. An exit interview was conducted where this report (LIC 809) was reviewed, discussed, then provided to Facility Representative
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2023
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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