366407059-9-6-2024-56-AS-MMAE-D8UPSK-20240906113429

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366407059
Report Date: 09/06/2024
Date Signed: 09/06/2024 11:34:41 AM

Document Has Been Signed on 09/06/2024 11:34 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:	RAINBOW GUEST HOME		FACILITY NUMBER:	366407059
ADMINISTRATOR:	MENCIAS, MARIO		FACILITY TYPE:	740
ADDRESS:	11205 DAYLILLY ST.		TELEPHONE:	(909) 357-0144
CITY:	FONTANA	STATE: CA	ZIP CODE:	92337
CAPACITY:	6	CENSUS: 3	DATE:	09/06/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Mario Mencias & Teodora Andrada		TIME COMPLETED:	11:40 AM

NARRATIVE

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Licensing Program Analysts (LPAs) Magda Malcore and Renese Howell-Small made an unannounced visit to the facility to conduct a required comprehensive annual inspection. LPAs met with Adminstrator, Mario Mencias and Staff,Teodora Andrada and were granted entry to the facility. The facility is a Residential Care Facility for Elderly (RCFE) with a license capacity of (6), and a current census of (3). LPAs conducted a general inspection of facility, which included, but was not limited to, the following:

Operation/Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). Indoor and outdoor passageways were kept free of obstruction. The facility has no swimming pools or similar bodies of water. The facility has sufficient indoor and outdoor space for resident activities. The facility is maintained at a comfortable temperature. Resident bedrooms were furnished with beds, night stands, chairs, bed linen and sufficient lighting. Resident bathroom was maintained clean and fixtures were operating properly. The hot water temperature in the bathroom measured at 105.3 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms, laundry equipment, and telephone service. The facility has posted in a common area Community Care Licensing complaint poster, Ombudsman poster, facility license, evacuation plan and emergency telephone numbers. LPAs observed a disinfectant spray was kept in an unlocked cabinet in resident's bathroom. The Administrator removed the disinfectant spray and placed it in a locked cabinet. LPAs observed sharps were kept in an unlocked kitchen drawer. The Administrator locked and secured the kitchen drawer.

Food Service: Kitchen and dining areas were maintained cleaned. Non-perishable and perishable food supply was sufficient for number of residents in care. The facility’s refrigerators and freezers were operating properly.

Care & Supervision: The facility staff schedule reflects 24 hour, 7 days a week staff coverage.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024

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: RAINBOW GUEST HOME	FACILITY NUMBER: 366407059
	VISIT DATE: 09/06/2024

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Health Related Services: The facility maintains record of resident’s medications and medications were centrally stored in a locked cabinet .

Record Review: Resident files reviewed had admissions agreements, physician’s reports, appraisals, needs and services plans. Staff files reviewed had First Aid/CPR certifications, criminal record clearances, training, and health screenings. The Administrator’s certification, facility’s insurance and emergency drill training were up-to-date.

Based on LPAs observations and records reviewed, deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted where reports (LIC809/LIC809-C/LIC809-D) were discussed and copies with Appeal Rights were provided to staff Andrada 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: 09/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/06/2024 11:34 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: RAINBOW GUEST HOME	FACILITY NUMBER: 366407059
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)(1)

87309 Storage Space (a)Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observations, the licensee did not comply with the section cited above by not ensuring disinfectants and sharps were kept in locked cabinet, inaccesible to residents in care; which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/07/2024
	Plan of Correction
1 2 3 4	During LPAs visit the Administrator ensured the sharps and disinfectants were kept locked. no further action is required.

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: 09/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024

LIC809 (FAS) - (06/04)

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