366403577-5-2-2024-56-AS-MMAE-D4VU85-20240502152059

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366403577
Report Date: 05/02/2024
Date Signed: 05/02/2024 03:21:17 PM

Document Has Been Signed on 05/02/2024 03:21 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:	CHRISTIAN LIFE & HOME CARE		FACILITY NUMBER:	366403577
ADMINISTRATOR:	SWANSON, JUDY A.		FACILITY TYPE:	740
ADDRESS:	1848 S. SHEDDEN DRIVE		TELEPHONE:	(909) 799-8245
CITY:	LOMA LINDA	STATE: CA	ZIP CODE:	92354
CAPACITY:	6	CENSUS: 5	DATE:	05/02/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Judy Swanson - Licensee		TIME COMPLETED:	03:30 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) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Judy Swanson, 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), a current census of (5) residents in care and a hospice waiver for (2). LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: Physical Plant/Environment: Indoor and outdoor passageways are free of obstruction. The facility has no swimming pools or similar bodies of water. Outdoor shaded area is sufficient for resident activities and is enclosed with a self-latching gate.The facility has sufficient lighting and is maintained at a comfortable temperature. The facility has operating carbon monoxide alarms and telephone service. Resident’s showers, toilets, and hand washing areas were operating in a safe and sanitary conditions. The hot water temperature in both resident bathrooms measured 107 degrees F. Four (4) resident’s bedrooms had beds, bed linen, chairs, storage space and sufficient lighting. 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, facility license, disaster evacuation plan and emergency telephone numbers. Food Service: Facility kitchen and dining areas are maintained clean. The facility has sufficient non-perishable and perishable food supply for residents in care. Sharps, disinfectants, and cleaning solutions were kept locked and inaccessible to residents in care.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024

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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CHRISTIAN LIFE & HOME CARE	FACILITY NUMBER: 366403577
	VISIT DATE: 05/02/2024

NARRATIVE

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Care & Supervision: Facility has 24-hour/7days a week care staff. Facility staff have current CPR/first aid training.

Medical Related Services: Resident’s medications are labeled and centrally stored in a locked cabinet. The facility sufficient first aid supplies.

Record Review: The Licensees' Administrator's certification is current. The facility’s last fire drill was conducted on 4/6/24. Staff files reviewed were observed to be complete. LPA review of (5) resident files reveals, resident #1 (R1) did not have a preadmission appraisal on file for review.

Based on observations and record review, technical violations and a deficiency is being cited per Title 22, of The California Code of Regulations.

This report and a plan of correction addressed in report LIC809-D was reviewed with the Licensee. Copies of the licensing reports were provided with Appeal Rights to the Licensee at the conclusion of the visit.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/02/2024 03:21 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: CHRISTIAN LIFE & HOME CARE	FACILITY NUMBER: 366403577
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Pre-Admission Appraisal


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 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
1 2 3 4	Based on LPA observations, the licensee did not comply with the section cited above by resident #1 (R1) did not have a preadmission appraisal on file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/06/2024
	Plan of Correction
1 2 3 4	The Licensee completed a resident appraisal during inspection. No further action is required.

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 Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024

LIC809 (FAS) - (06/04)

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