366405771-9-18-2024-56-AS-SRAZ-D98T3Y-20240918142308

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366405771
Report Date: 09/18/2024
Date Signed: 09/18/2024 02:23:17 PM

Document Has Been Signed on 09/18/2024 02:23 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:	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: 5	DATE:	09/18/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:07 PM
MET WITH:	Administrator Nelfa Reeder		TIME COMPLETED:	02:35 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) Sarina Ramirez made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Administrator Nelfa Reeder 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). LPA Ramirez 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 pool or similar bodies of water. Outdoor shaded area is sufficient for resident activities. The facility has sufficient lighting and is maintained at a comfortable temperature. The facility is equipped with operating smoke detectors/carbon monoxide alarms and telephone service. Resident’s showers and toilets were operating properly. The hot water temperature in (2) residents bathrooms measured at 109.7 and 108 degrees F. Three (3) resident’s bedrooms had beds, bed linen, chairs, dresser, storage space and sufficient lighting. The facility has sufficient linens, towels, and personal hygiene items for residents. The facility has posted in a common area, CCLD complaint poster, Ombudsman poster, facility license, disaster facility sketch, emergency telephone numbers, and disaster plan. 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 and chemicals were kept locked and inaccessible to residents in care. Continuation on LIC – 809C

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Sarina Ramirez	TELEPHONE: (951) 248-0307
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024

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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Document Has Been Signed on 09/18/2024 02:23 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: REST HAVEN CARE HOME	FACILITY NUMBER: 366405771
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87412(a)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in not having an updated CPR certificate for S#2 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/19/2024
	Plan of Correction
1 2 3 4	Licensee agreed to submit an updated CPR certificate for S#2 by the POC 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: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Sarina Ramirez	TELEPHONE: (951) 248-0307
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/18/2024 02:23 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: REST HAVEN CARE HOME	FACILITY NUMBER: 366405771
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87208(a)(12)

Plan of Operation

(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: (12) The Infection Control Plan pursuant to Section 87470. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above by not developing the required Infection Control Plan for the facility which poses a potential health, safety or personal rights risk to persons in care
	POC Due Date: 09/30/2024
	Plan of Correction
1 2 3 4	Licensee stated to develop the required Infection Control Plan and submit to LPA Ramirez by Plan of Correction (POC) 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: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Sarina Ramirez	TELEPHONE: (951) 248-0307
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: REST HAVEN CARE HOME	FACILITY NUMBER: 366405771
	VISIT DATE: 09/18/2024

NARRATIVE

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Care & Supervision: Facility has 24-hour/7days a week care staff.

Medical Related Services: Resident’s medications are labeled and centrally stored in a locked cabinet.

Record Review: Three (3) Staff files reviewed, staff #2 has an expired CPR certificate, deficiency will be cited. Five (5) Resident files reviewed were observed to be complete.

Based on observations and record review deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted where reports (LIC809 & LIC809-D) were discussed and copies were provided with appeal rights to Administrator Nelfa Reeder.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Sarina Ramirez	TELEPHONE: (951) 248-0307
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024

LIC809 (FAS) - (06/04)

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