366408649-7-18-2023-56-AS-MMAE-CTUS25-20230718132859

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366408649
Report Date: 07/18/2023
Date Signed: 07/18/2023 01:29:09 PM

Document Has Been Signed on 07/18/2023 01:29 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:	ALOHA PRIVATE HOME CARE		FACILITY NUMBER:	366408649
ADMINISTRATOR:	VENDIOLA, HEIDI C.		FACILITY TYPE:	740
ADDRESS:	24944 TULIP AVENUE		TELEPHONE:	(909) 796-6965
CITY:	LOMA LINDA	STATE: CA	ZIP CODE:	92354
CAPACITY:	6	CENSUS: 3	DATE:	07/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	Heidi Vendiola, Licensee		TIME COMPLETED:	01:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Heidi Vendiola, Licensee and discussed the purpose of the visit.

The facility is a Residential Care Facility for the Elderly (RCFE). Licensed capacity is (6) with a hospice waiver for (2). The current census is (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 passageways were kept free of obstruction. The facility has sufficient furniture and activity space for clients in care. The facility has sufficient lighting and is maintained at a comfortable temperature 77 degrees F.

LPA inspected the kitchen. Facility has sufficient non-perishable and perishable food for the number of clients in care. Facility has a sample menu on file. Sharps are stored and kept locked and inaccessible to clients in care. LPA observed grime above the kitchen stove and wall. Licensee stated that the stove vent was not working properly causing the grime. Licensee had facility staff immediately clean the area. LPA observed flies in a open container with full of grapes. LPA observed on flies on lemons and grapefruit which were set on the kitchen counter. Licensee immediately discarded the fruit. Deficiency cited.

LPA inspected (3) client bedrooms. Bedrooms are equipped with required furniture such as: mattresses, nightstands, chairs and storage space. Bedrooms have sufficient linen and lighting.

LPA inspected (3) client bathrooms. Bathrooms were equipped with handrails and operating in safe and sanitary conditions.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023

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: ALOHA PRIVATE HOME CARE	FACILITY NUMBER: 366408649
	VISIT DATE: 07/18/2023

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LPA observed the facility is equipped with operating carbon monoxide alarms and fully charged fire extinguisher. Fireplace adequately screened and operating telephone service. Posters such as personal rights, Complaint reporting, Ombudsman reporting, the disaster plan were posted in a common area. Cleaning supplies, toxins, items were kept locked and inaccessible to clients in care.

Medications are kept in a safe and locked cabinet inaccessible to clients in care. LPA reviewed (3) client medications. All medication were administered as prescribed and labeled as required by State and Federal laws. LPA file review reveals that medication records were not updated. Deficiency cited.

All staff files reviewed for criminal record clearance, training, and health screenings. LPA file review revealed Administrator/Licensee certification is expired. Licensee stated they are in process of renewing the certification and sent the certified check to Licensing on 5/16/23. All client records reviewed has admissions agreements, physician's report, and personal rights statements.

Based on the observations made during today’s visit, Deficiencies were cited during this visit.

An exit interview was conducted where report(s) LIC809, LIC809C, LIC809D, LIC9102 were discussed and a copy with appeal rights was provided to the Licensee 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: 07/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/18/2023 01:29 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: ALOHA PRIVATE HOME CARE	FACILITY NUMBER: 366408649
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87555(b)(27)

General Food Service Requirements

(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observations, the licensee did not comply with the section cited above, in the kitchen, LPA observed an open container with grapes had several flies in it. LPA observed flies on lemons and grapefruit which were on the counter. LPA observed grime above the kitchen stove and wall; which poses an immediate health, safety or personal rights risk to (3) out of (3) persons in care.
	POC Due Date: 07/19/2023
	Plan of Correction
1 2 3 4	Licensee had facility staff immediately clean the area. Licensee immediately discarded the fruit. Licensee to read and complete a statement of understanding on the above cited regulation by 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) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 07/18/2023 01:29 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: ALOHA PRIVATE HOME CARE	FACILITY NUMBER: 366408649
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)(6)(A)

Personnel Records

(A) For administrators this shall include verification that he/she meets the educational requirements in Section 87405(d) through (g). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA record review, the licensee did not comply with the section cited above. LPA file review revealed Administrator/Licensee certification is expired. Licensee stated they are in process of renewing the certification and sent the certified check to Licensing on 5/16/23; which poses/posed a potential health, safety or personal rights risk to three (3) out of (3)persons in care.
	POC Due Date: 07/31/2023
	Plan of Correction
1 2 3 4	Administrator/Licensee to provide proof of current Administrator certification by POC date.

Type B

Section Cited

CCR

87465(a)(6)

Incidental Medical and Dental Care Services

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA file review, the licensee did not comply with the section cited above in. LPA reviewed medication records were not updated; which poses/posed a potential health, safety or personal rights risk to three (3) out of (3) persons in care.
	POC Due Date: 07/31/2023
	Plan of Correction
1 2 3 4	Licensee stated that they will update the logs and provide licensing submit copies of medication logs weekly to Licensing for review until 7/31/23.

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: 07/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023

LIC809 (FAS) - (06/04)

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