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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366408320
Report Date: 05/31/2022
Date Signed: 05/31/2022 03:39:22 PM

Document Has Been Signed on 05/31/2022 03:39 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:LMB CARE HOMEFACILITY NUMBER:
366408320
ADMINISTRATOR:BRANDON DELGADOFACILITY TYPE:
735
ADDRESS:1125 WEST "J" STREETTELEPHONE:
(909) 460-9372
CITY:ONTARIOSTATE: CAZIP CODE:
91762
CAPACITY: 6CENSUS: 3DATE:
05/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Licensee/Administrator Marilyn DelgadoTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Melody Brown arrived at the facility 05/31/2022 at 02:15 PM announced, in order to amend the report issued last 05/26/2022 at 12:00 PM which was typed at facility LMB Care Home - 336408858 due to computer error for the the facility's Annual Inspection.

LPA Brown met with Licensee/Administrator Marilyn Delgado and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. Below is a summary of what was observed:

Infection Control: LPA Brown went over COVID-19 best practices for infection control and prevention with Licensee/Administrator Delgado. Per documents review, Mitigation Plan was submitted 04/08/2021.

LPA Brown observed the facility having Covid-19 signages throughout the facility for proper hand washing procedure and social distancing, but no signs have been posted at facility entrance with updates to visitor policy to notify of policies and procedures necessary to protect residents from infection during pandemic. LPA Brown will be issuing a Technical Advisory note for this item. LPA Brown toured the facility's and all rooms and bathrooms have hand soap and paper towels. LPA Brown requested to inspect the facility's Personal Protective Equipment (PPE) supply and the facility has sufficient supply of PPE, however, LPA Brown observed no isolation gowns available at the facility. LPA Brown will be issuing a Technical Assistance Advisory Note instead of a deficiency due it being difficult to access isolation gowns at numerous points during the COVID-19 pandemic. LPA Brown advised the facility to look online for items missing from their PPE supply kit, as Community Care Licensing Department (CCLD) and Inland Regional Center (IRC) may not have these items to supply them with.
**** Continuation in LIC809C ****

***This LIC809 is in reference with the Annual Visit conducted last 05/26/2022 typed in LMB Care Home - 336408858 due to computer error.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2022
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 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: LMB CARE HOME
FACILITY NUMBER: 366408320
VISIT DATE: 05/31/2022
NARRATIVE
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LPA Brown went over the various recommended training for facility staff with Licensee/Administrator Delgado in relation to COVID-19 and Licensee/Administrator Delgado informed LPA Brown that all staff are trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing of PPE.

LPA Brown inquired as to if staff have been fit tested for N95 masks, and Administrator Delgado informed LPA Brown that all staff have not been fit tested at this time. LPA Brown will be issuing a deficiency during today's inspection for staff not being fit tested for N95 masks due to the facility having covid positive staff last 01/24/2022, and N95 masks needs to be worn when a client or staff is COVID-19 positive or under observation while awaiting test results.

Additionally LPA Brown observed all clients and most staff have been vaccinated and boosted and are practicing other COVID-19 precautions, which minimize the risk of them contracting COVID-19. LPA Brown will be providing Licensee/Administrator Delgado with the information for Provider Information Notice (PIN) PIN-21-10-ASC which contains resources for getting staff fit tested for N95 masks.

The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the proper use and disposal of PPE and overall infection control. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and their clients, when and how to isolate/quarantine clients, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas. The facility also has a plan in place to monitor their clients regularly for any changes in condition and to subsequently notify the clients physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses.

*** Continuation in LIC809C ***

***This LIC809 is in reference with the Annual Visit conducted last 05/26/2022 typed in LMB Care Home - 336408858 due to computer error.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2022
LIC809 (FAS) - (06/04)
Page: 3 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: LMB CARE HOME
FACILITY NUMBER: 366408320
VISIT DATE: 05/31/2022
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During the tour of the facility on 05/26/2022 at 12:30 PM, LPA Brown observed the facility side fence gate locked from the inside. LPA Brown informed Licensee/Administrator Delgado that the facility fence side gate must not be locked as this poses immediate risks to residents in care. Licensee/Administrator Delgado stated that facility side fence gate was locked last night due to police activity in the neighborhood. Licensee/Administrator Delgado immediately unlocked the facility side fence gate during the visit.


During the visit, LPA Brown requested staff vaccination records and on 05/26/2022 at 12:45 PM, LPA Brown observed Staff 1 and Staff 4 are both vaccinated and boosted. However, no booster vaccination/exemption for Staff 2 and Staff 3 maintained at the facility. LPA Brown will be issuing a deficiency for this item as this poses potential risk to clients in care.

An exit interview was conducted with Licensee/Administrator Marilyn Delgado and a copy of this report (LIC809), LIC 809D, LIC9102 TA Advisory Notes and Appeal Rights were discussed and provided.

***This LIC809 is in reference with the Annual Visit conducted last 05/26/2022 typed in LMB Care Home - 336408858 due to computer error.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2022
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 05/31/2022 03:39 PM - It Cannot Be Edited


Created By: Melody Brown On 05/31/2022 at 02:54 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: LMB CARE HOME
FACILITY NUMBER: 366408320

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/31/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80072(a)(2)
Personal Rights
(a) Each client shall have personal rights including: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not providing N95 respirator fit test to all staff which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/23/2022
Plan of Correction
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2
3
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Licensee stated to provide N95 respirator fit test to all the staff and submit proof to LPA Brown by POC due date.
Type B
Section Cited
HSC
121125,120140,120275


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation,(interview and record review, the licensee did not comply with the section cited above by not ensuring the personal rights of persons in care to live in a safe, healthy, comforatble home failed to comply with reporting and personnel requirements and engaged in conduct inimical to the health, welfare and safety of persons in care in that the LIcensee did not verify workers vaccination booster or exemption status or unvaccinated workers test result as applicable by maintaining a record as required by State Public Officer Order of December 22, 2021 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/10/2022
Plan of Correction
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3
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Licensee stated to submit proof of booster vaccination/exemption of Staff 2 and Staff 3 to LPA Brown by POC due date and update all staff vaccination record at the facility and submit proof to LPA Brown by POC due 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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2022


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 05/31/2022 03:39 PM - It Cannot Be Edited


Created By: Melody Brown On 05/31/2022 at 03:04 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: LMB CARE HOME
FACILITY NUMBER: 366408320

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/31/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)(2)

80020 Fire Clearance (a) All facilities shall secure and maintain a fire clearnace approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshall. (2) Prior to the use of secuired perimeters, an applicant or licensee for an Adult Residential Facility or Group HOme shall meet the fire clearnace approval requirements of Title 17, Division 2, Chapter 3, Subchapter 4, Article 12, Section 56072(d) and (h).
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by locking the facility side fence gate which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/27/2022
Plan of Correction
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Licensee immediately unlocked the facility side fence gate during the visit.
Licensee stated to submit Statement of Understanding to 80020(a)(2) and submit it to LPA Brown by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2022


LIC809 (FAS) - (06/04)
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