366405771-9-11-2023-56-AS-MMAE-CVKUHS-20230911153627

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366405771
Report Date: 09/11/2023
Date Signed: 09/11/2023 03:36:40 PM

Document Has Been Signed on 09/11/2023 03:36 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:	REST HAVEN CARE HOME		FACILITY NUMBER:	366405771
ADMINISTRATOR:	REEDER, NELFA		FACILITY TYPE:	740
ADDRESS:	11530 ORANGE GROVE		TELEPHONE:	(909) 328-2569
CITY:	LOMA LINDA	STATE: CA	ZIP CODE:	92354
CAPACITY:	6	CENSUS: 3	DATE:	09/11/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Nelfa Reeder, Administrator		TIME COMPLETED:	03:35 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 Nelfa Reeder, Administrator, and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE). License capacity of (6) with a current census of (3). LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: LPA inspected the facility inside and out. Indoor and outdoor passageways are free of obstruction. The facility has sufficient lighting and is maintained at a comfortable temperature. Facility has no outdoor bodies of water. Facility has covered patio space for clients and fenced backyard. LPA inspected the kitchen. Hot water temperature is maintained at 106 degrees F. Facility has sufficient non-perishable and perishable food supply for clients in care. Facility has sufficient cups, plates, and utensils for client use. LPA inspected client bedrooms. Bedrooms are equipped with beds, nightstands, chairs, sufficient linen and lighting. LPA inspected client bathrooms. Bathroom equipment is operating in safe and sanitary conditions. Bathroom hot water temperatures tested between 105 and 106 degrees F.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023

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 5

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: REST HAVEN CARE HOME	FACILITY NUMBER: 366405771
	VISIT DATE: 09/11/2023

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
26
27
28
29
30
31
32

LPA observed the facility is equipped with operating carbon monoxide alarm and operating telephone service. Posters such as complaint telephone number, Ombudsman telephone number, emergency phone numbers are posted in a common area. Emergency drill was conducted on 7/5/23. Facility has a complete first aid kit. Facility has sufficient linen, emergency supplies, and personal hygiene products for clients. Sharps, disinfectants, cleaning solutions, and toxins are kept in a locked cabinet. LPA observed front door signal system was not operating. Administrator stated the signal system was turned off during maintenance. Administrator stated they are not sure when the maintenance person will be returning. Deficiency cited.
Client medications are kept in a safe and locked cabinet, inaccessible to clients in care. LPA observed client 1's (C1) medication packet was empty. Administrator stated medication was refilled and will arrive today. Deficiency cited.
All staff files reviewed had first aid certifications, fingerprint clearances/exemptions, health screenings, training, and personnel records.
All client records reviewed had admissions agreements, physician's reports, assessments, personal rights, and safeguarded resource records.
An exit interview was conducted, where licensing reports and plan of corrections were discussed. Copies of reports with appeal rights were provided to the Administrator 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: 09/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023

LIC809 (FAS) - (06/04)

Page: 2 of 5

Document Has Been Signed on 09/11/2023 03:36 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: REST HAVEN CARE HOME	FACILITY NUMBER: 366405771
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(c)(2)

Incidental Medical and Dental Care Services

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation and interviews, the licensee did not comply with the section cited above by client 1's (C1) medication packet was empty. Administrator stated medication was refilled and will arrive todaywhich poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/12/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator shall submit to the licensing agency proof of client medication received by POC 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: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 09/11/2023 03:36 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: REST HAVEN CARE HOME	FACILITY NUMBER: 366405771
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.605

Other Provisions

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation and interviews, the licensee did not comply with the section cited above by not maintaining injury liability insurance. Administrator stated that the insurance was cancelled due to having to pay high rates, this poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/30/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator shall submit to the licensing agency proof of insurance by POC date.

Type B

Section Cited

CCR

87303(i)

Maintenance and Operation

(i) Facilities shall have signal systems which shall meet the following criteria: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observations and interviews, the licensee did not comply with the section cited above, LPA observed front door signal system was not operating. Administrator stated the signal was turned off during maintenance. Administrator stated they are not sure when the maintenance person will be returning, this poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/30/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator shall submit to the licensing agency proof of operating signal system by POC 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 Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023

LIC809 (FAS) - (06/04)

Page: 4 of 5