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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530071
Report Date: 01/05/2024
Date Signed: 01/05/2024 05:21:08 PM


Document Has Been Signed on 01/05/2024 05:21 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:CTR HOME CARE LLCFACILITY NUMBER:
365530071
ADMINISTRATOR:PEREZ, APOLINARIOFACILITY TYPE:
740
ADDRESS:11490 RICHMONT ROADTELEPHONE:
(909) 894-3852
CITY:LOMA LINDASTATE: CAZIP CODE:
92354
CAPACITY:6CENSUS: 4DATE:
01/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Apolinario Perez, LicenseeTIME COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Apolinario Perez, Licensee, and discussed the purpose of the visit.

The facility is a Residential Care Facility for the Elderly (RCFE) with a license capacity of (6) and a current census of (4) residents in care. The facility has a hospice waiver for (3) residents. LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:

Physical Plant: Indoor and outdoor passageways are free of obstruction. The facility has no bodies of water accessible to residents in care. The facility is maintained at a comfortable temperature and has sufficient lighting, and indoor space for resident activities. The facility backyard is fenced and sufficient for resident activities.
Resident’s bathrooms were operating in safe and sanitary conditions. The hot water temperature in residents' bathrooms measured between 106- and 111-degrees F. Resident’s bedrooms have sufficient lighting and furniture in good repair. Facility has operating carbon monoxide alarms and telephone service. The facility has sufficient linen, towels, and personal hygiene items for residents. The facility has posted in a common area, Community Care Licensing complaint poster, Ombudsman poster, resident's personal rights, disaster evacuation plan and emergency telephone numbers.

Food Service: Facility has sufficient non-perishable and perishable food supply for residents in care. The refrigerator and freezer are operating in a healthful manner. Sharps, pesticides and other cleaning solutions were kept locked and stored away from food areas.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:
DATE: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 7


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: CTR HOME CARE LLC
FACILITY NUMBER: 365530071
VISIT DATE: 01/05/2024
NARRATIVE
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Care & Supervision: Facility has 24-hour, 7 days a week care support staff.

Record Review: Licensees' Administrator’s certification expires on 3/17/2024. (4) staff files were reviewed. Staff record review reveals, the facility did not maintain records of First Aid/CPR training and completed health screening for staff #1 (S1) and staff #2 (S2). Resident record reviews reveals, the facility did not maintain completed preplacement appraisals for resident #1 (R1) and resident #2 (R2).

Medical Related Services: Facility has complete First Aid kits with manual. All medication is centrally stored and kept in a locked cabinet.

Based on LPA observations and record review, deficiencies are being cited per Title 22, Division 6 of The California Code of Regulations.

An exit interview was conducted where reports LIC809, LIC809-C, LIC809D, and LIC9102 were discussed. Copies of the reports with Appeal Rights were provided to the Licensee at the conclusion of the visit.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 01/05/2024 05:21 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: CTR HOME CARE LLC
FACILITY NUMBER: 365530071

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Personnel Records
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review, the licensee did not comply with the section cited above by the facility did not have a complete health screening for staff #1 (S1) and staff #2 (S2), which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/15/2024
Plan of Correction
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The Licensee shall submit to the Licensing Agency proof of staff health screening including tuberculosis results by POC due 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: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:
DATE: 01/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2024
LIC809 (FAS) - (06/04)
Page: 3 of 7


Document Has Been Signed on 01/05/2024 05:21 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: CTR HOME CARE LLC
FACILITY NUMBER: 365530071

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review, the licensee did not comply with the section cited above by the facility did not maintain records of First Aid/CPR training for staff #1 (S1) and staff #2 (S2), which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/15/2024
Plan of Correction
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Licensee shall submit to the Licensing Agency proof of training by POC due date.
Section Cited
Other Provisions
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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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: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:
DATE: 01/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2024
LIC809 (FAS) - (06/04)
Page: 4 of 7


Document Has Been Signed on 01/05/2024 05:21 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: CTR HOME CARE LLC
FACILITY NUMBER: 365530071

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Pre-Admission Appraisal
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
Type B
Section Cited
CCR
87457(c)(1)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. (1) The appraisal shall include, at a minimum, an evaluation of the prospective resident's functional capabilities, mental condition and an evaluation of social factors as specified in Sections 87459, Functional Capabilities and 87462, Social Factors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review, the licensee did not comply with the section cited above by the facility did not maintain completed preplacement appraisals for resident #1 (R1) and resident #2 (R2), which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/02/2024
Plan of Correction
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Licensee shall submit to the Licensing Agency proof of completed assessments by POC due 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: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:
DATE: 01/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2024
LIC809 (FAS) - (06/04)
Page: 5 of 7