<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366405715
Report Date: 11/09/2023
Date Signed: 11/09/2023 12:20:14 PM


Document Has Been Signed on 11/09/2023 12:20 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:L & S LIFECAREFACILITY NUMBER:
366405715
ADMINISTRATOR:TOLENTINO, LISAFACILITY TYPE:
740
ADDRESS:25141 PROSPECT AVENUETELEPHONE:
(909) 796-5184
CITY:LOMA LINDASTATE: CAZIP CODE:
92354
CAPACITY:6CENSUS: 6DATE:
11/09/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Lisa Tolentino, AdministratorTIME COMPLETED:
12:20 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 conducted an unannounced case management visit to the facility, based on deficiencies observed during complaint investigation #56-AS-20231107154843. LPA Malcore met with Lisa Tolentino, Administrator and discussed the purpose of the visit.

The facility currently retains residents with Dementia. LPA observed the front door and back door alarms were not working. The Administrator stated the alarms are working but the back door alarm is turned off during the day because it causes a disturbance to the residents. The Administrator stated that front door alarm is always on. LPA requested the Administrator to open the front door to test the alarm. The Administrator opened the door and no sound was heard. LPA observed the Administrator and another staff moving the alarm switch to different positions until the sound of the front door alarm was heard.

Based on LPA observations, a deficiency is being cited during today’s visit. An exit interview was conducted where reports LIC809 and LIC809-D were discussed. Copies of the reports with appeal rights were provided to the Administrator 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: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2023
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 2


Document Has Been Signed on 11/09/2023 12:20 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: L & S LIFECARE
FACILITY NUMBER: 366405715

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/10/2023
Section Cited
CCR
87705(j)

1
2
3
4
5
6
7
87705 Care of Persons with Dementia(j)The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The Administrator turned on the auditory devices during LPA's today's visit. In addition, the Administrator shall submit to the Licensing agency a statement of understanding on the regulation cited by POC due date.
8
9
10
11
12
13
14
based on LPA observations, the licensee did not comply with the section cited above by back and front door alarms were observed not on, which poses an immediate health, safety or personal rights risk to persons in care with wandering behaviors.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 11/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2