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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530012
Report Date: 12/21/2023
Date Signed: 12/21/2023 03:06:48 PM

Document Has Been Signed on 12/21/2023 03:06 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: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:
12/21/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Lori Secord, Program DirectorTIME COMPLETED:
03:10 PM
NARRATIVE
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Helping Hearts - Acacia Social Rehabilitation Facility to conduct a Case Management Visit. This Case Management Visit is in response to incident reports regarding medication errors on 12/18/23. LPA was greeted by Program Director, Lori Secord at the door and granted entry. LPA introduced self and stated purpose of the visit.

The Special/Unusual Incident Report, (SIR) was submitted to the Community Care Licensing Office on 12/19/23 reporting that on 12/18/23 it was discovered that Resident #1, (R1) was not given a 4pm dose of prescribed medications. R1's medical insurance - advice nurse, public guardian and the Program Director was notified upon the discovery.

According to staff interviews, the staff member responsible is a new staff member. When a new staff member starts working at the facility, they are provided hands on training then later a company wide new employee orientation which is more comprehensive. More comprehensive medication training specifically. Because this staff member has not been back on duty since the incident, Program Director has not had a chance to inquire about the specific details of the incident or provide the additional training to aid in preventing the occurrence in the future.

LPA previously completed a case management visit on 12/5/23 in relation to medication errors occurring on 11/22/23 and 11/27/23. Which also involved a new employee, only being provided hands on training before the comprehensive training at orientation could be provided. LPA and Program Director discussed methods of providing medication training new employees sooner than the company wide orientation can take place to aid in prevention of medication errors.

Please see LIC809-C
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2023
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 12/21/2023 03:06 PM - It Cannot Be Edited


Created By: Amber Coleman On 12/21/2023 at 02:50 PM
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: HELPING HEARTS ACACIA
FACILITY NUMBER: 365530012

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/22/2024
Section Cited
CCR
80075(5)(B)

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80075 Health Related Services (5)(B)
Once ordered by the physician the medication is given according to the physician's directions.

This requirement was not met as evidenced by:
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Program Director agrees to review the Title 22, Division 6, of the California Code and Regulation (CCR), Section 80075(5)(B) and submit a letter of understanding; by way of an LIC9098. Additionally, Program Director shall provide training on the section cited to all staff involved.
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Based on interviews and record reviews, Program Director/Administrator did not ensure that R1’s medication is given according to the physician’s directions, which poses a potential risk to the health and safety to persons in care.
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Licensee shall submit a letter of understanding to the Regional Office (RO) with verification of in-service within the next 30 business days.

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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 Brown
LICENSING EVALUATOR NAME:Amber Coleman
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2023


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: HELPING HEARTS ACACIA
FACILITY NUMBER: 365530012
VISIT DATE: 12/21/2023
NARRATIVE
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Based on observations and interviews, a deficiency will be cited to address the above mentioned concerns; per Title 22, Division 6 section 80075 (5)(B). Please see LIC809D. LPA observed no concerns for health and safety during the visit. An exit interview was conducted where this report was reviewed, discuss, then provided to Program Director, Lori Secord.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
LIC809 (FAS) - (06/04)
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