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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366403161
Report Date: 09/06/2023
Date Signed: 09/06/2023 11:39:56 AM


Document Has Been Signed on 09/06/2023 11:39 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:NORTH SAN ANTONIO SENIOR CARE IIFACILITY NUMBER:
366403161
ADMINISTRATOR:SCHWARCZ, ERICFACILITY TYPE:
740
ADDRESS:938 W. 22ND STREETTELEPHONE:
(909) 931-2123
CITY:UPLANDSTATE: CAZIP CODE:
91784
CAPACITY:6CENSUS: 5DATE:
09/06/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Eric Schwarcz- AdministratorTIME COMPLETED:
11:50 AM
NARRATIVE
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Licensing Program Analyst (LPA) Ryan Gardner made an unannounced case management visit to conduct a Health and Safety check of the residents in care at the facility. LPA met with Administrator Eric Schwarcz and explained the reason for the visit.

During today's visit, LPA obtained documents relating to a self reported incident that occurred on 8/28/2023 involving two (2) residents.

The Health and Safety check included overall observation of the facility inside, and outside, including food supply, medications, physical plant, and the residents in care. LPA observed the following safety concerns in the kitchen:

The key to the knives drawer was hanging on a black string from the knives drawer near the pack lock giving the residents access to open the knives drawer. LPA observed sharp knives in the drawer. The key to the chemical cabinet was hanging on a black string on the cabinet near the pad lock giving the residents access to open the chemicals cabinet. LPA observed bleach and disinfectants in the cabinet. The key to the resident’s medications was hanging on a black string from the medication cabinet near the pad lock giving the residents access to the medications. LPA observed the resident’s medications in the medication cabinet. After the kitchen tour was complete, Staff S1 used a pair of scissors to cut the black strings with the keys off of the knives drawer, the chemicals cabinet, and the medication cabinet.

Based on the observations made during today’s visit, three (3) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809) and LIC809D forms were discussed and provided to Administrator Eric Schwarcz, along with a copy of the appeal rights.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2023
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 3


Document Has Been Signed on 09/06/2023 11:39 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: NORTH SAN ANTONIO SENIOR CARE II
FACILITY NUMBER: 366403161

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/07/2023
Section Cited
CCR
87705(f)(1)

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87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
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The licensee has agreed to read regulation 87705 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to remove the key hanging from the knives drawer and find a secure place to store the key.
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Based on observation and interview the licensee did not comply with the section cited above evidenced by having the key to open the knives hanging from the knives drawer that allows the residents access to the knives which poses an immediate health, safety, or personal rights risk to persons in care.
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The licensee has agreed to train the staff on properly securing the knives and send LPA proof the training was completed by POC due date 9/7/2023.
Type A
09/07/2023
Section Cited
CCR87705(f)(2)

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87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
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The licensee has agreed to read regulation 87705 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to remove the key hanging from the chemical cabinet and find a secure place to store the key.
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Based on observation and interview the licensee did not comply with the section cited above evidenced by having the key to open the chemicals hanging on the chemical cabinet that allows the residents access to the chemicals (bleach and disinfectants) which poses an immediate health, safety, or personal rights risk to persons in care.
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The licensee has agreed to train the staff on properly securing the chemicals and send LPA proof the training was completed by POC due date 9/7/2023.
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: Efren MalagonTELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 09/06/2023 11:39 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: NORTH SAN ANTONIO SENIOR CARE II
FACILITY NUMBER: 366403161

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/07/2023
Section Cited
CCR
87465(h)(2)

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Incidental Medical and Dental Care (h)The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
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The licensee has agreed to read regulation 87465 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to remove the key hanging from the medication cabinet and find a secure place to store the key.
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Based on observation and interview the licensee did not comply with the section cited above evidenced by having the key to open the medications hanging on the medication cabinet that allows the residents access to the medications which poses an immediate health, safety, or personal rights risk to persons in care.
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The licensee has agreed to train the staff on properly securing the medications and send LPA proof the training was completed by POC due date 9/7/2023.

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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: Efren MalagonTELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3