365530085-2-26-2024-56-AS-BWOT-D2TVZ4-20240226155206

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 365530085
Report Date: 02/26/2024
Date Signed: 02/26/2024 03:52:18 PM

Document Has Been Signed on 02/26/2024 03:52 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	ABBEY'S HOME, LLC		FACILITY NUMBER:	365530085
ADMINISTRATOR:	TESFASILASE, NAZARETH		FACILITY TYPE:	740
ADDRESS:	7883 PORTOFINO ST		TELEPHONE:	(909) 782-6925
CITY:	HIGHLAND	STATE: CA	ZIP CODE:	92346
CAPACITY:	6	CENSUS: 1	DATE:	02/26/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:38 AM
MET WITH:	Nazareth Tesfasilase		TIME COMPLETED:	04:00 PM

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) Anna Bueno & Bianca Wolcott arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by Jasmine Walker (Volunteer) and Veronica Desarnito (Staff) and granted entry. LPA began inspection with introduction, visit purpose and provided the facility caregiver with LPA identification and business card. Administrator Nazareth Tesfasilase shortly arrived at facility. Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. LPAs observed the facility to be clean and in good repair. The home is maintained at a comfortable temperature for the residents. Lighting is sufficient for safety and comfort. Water temperature measured within range. Grab bar chair is present in the restroom. Laundry facility room is locked with cabinets present for storing laundry soap. LPAs observed a unlocked cabinet under kitchen sink and hallway closet with cleaning supplies and chemicals. Unlocked cleaning supplies and chemicals could pose a danger if readily available to clients shall be stored where inaccessible to clients. Fire extinguishers are charged, mounted. All outdoor and indoor passageways are free of obstruction. Night lights and emergency lighting is present. A locked area is provided for medications and sharp objects. There is a telephone working at this location. The LIC 610E, emergency disaster plan is maintained. Emergency Drills are not being maintained, this poses a potential health and safety risk. The facility has a current written definitive plan of operation. The facility is maintained in conformity with the regulations adopted by the state fire marshal. The facility does not handle resident money. Refrigerator is 40 degrees, and freezer is -0 degrees. Personnel Records/Training/and Staffing-. No personal records were present for Administrator or Staff this poses a potential health and safety risk to clients. Additional LPAs observed Staff 1 (S1) had no criminal record clearance and was assisting resident. Which poses a immediate health, safety or personal rights risk to persons in care. LPAs were informed by S1 that they have been assisting with this facility for almost a year. A civil penalty of $500 was assessed on today's visit 2/26/24.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Bianca Wolcott	TELEPHONE: (951) 248-0306
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ABBEY'S HOME, LLC	FACILITY NUMBER: 365530085
	VISIT DATE: 02/26/2024

NARRATIVE

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Resident Records/Incident Reports/Personal Rights/Residents with Special Needs/Incidental Medical and Dental- LPA began review of resident records. One (1) record was reviewed. LPA reviewed for admission agreement, medical assessment and consent forms, appraisal needs and service plans, centrally stored medication/destruction records, and personal rights notification.

Refer to LIC809D for deficiencies cited. An exit interview was conducted where this report, LIC421BG, and appeal rights were discussed and provided to the administrator.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Bianca Wolcott	TELEPHONE: (951) 248-0306
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/26/2024 03:52 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ABBEY'S HOME, LLC	FACILITY NUMBER: 365530085
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observation, the licensee did not comply with the section cited above in licensee could not provide criminal record clearance for staff which poses a immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/27/2024
	Plan of Correction
1 2 3 4	Uncleared Staff needs to be removed until Criminal Clearance is received. Volunteers without proper clearance will not be allowed to work until proper clearance is received or supervised by associated Staff. Licensee shall submit POC before due date.

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: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Bianca Wolcott	TELEPHONE: (951) 248-0306
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2024

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 02/26/2024 03:52 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ABBEY'S HOME, LLC	FACILITY NUMBER: 365530085
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(g)

Personnel Records

(g) All personnel records shall be maintained at the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation, the licensee did not comply with the section cited above in licensee could not provide personnel records for staff which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/11/2024
	Plan of Correction
1 2 3 4	Administrator will submit personal records to LPA via email by POC due date.

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observation, the licensee did not comply with the section cited above in licensee could not provide emergency drills for staff which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/11/2024
	Plan of Correction
1 2 3 4	Administrator will submit emergency drills to LPA via email 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: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Bianca Wolcott	TELEPHONE: (951) 248-0306
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2024

LIC809 (FAS) - (06/04)

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