366410284-2-15-2024-56-AS-MMAE-D2GVXC-20240215154918

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366410284
Report Date: 02/15/2024
Date Signed: 02/15/2024 03:49:29 PM

Document Has Been Signed on 02/15/2024 03:49 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:	ADVENT LIFE CARE #2		FACILITY NUMBER:	366410284
ADMINISTRATOR:	LETICIA CERDENIO		FACILITY TYPE:	740
ADDRESS:	11532 BUTTERFIELD ST		TELEPHONE:	(909) 799-7853
CITY:	LOMA LINDA	STATE: CA	ZIP CODE:	92354
CAPACITY:	6	CENSUS: 2	DATE:	02/15/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:16 PM
MET WITH:	Leticia Cerdenio, Administrator		TIME COMPLETED:	03:45 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 conducted an unannounced annual visit to the facility. LPA met with Leticia Cerdenio, Administrator, and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) with a license capacity of (6) and a current census of (2) residents in care. The facility has a hospice waiver for (3) residents and currently has no residents on hospice care. LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: Physical Plant: Indoor and outdoor passageways are free of obstruction. The facility has no swimming pools or similar bodies of water. Outdoor shaded area is sufficient for resident activities and is enclosed with self-latching gates. The facility has sufficient lighting and is maintained at a comfortable temperature. Resident’s bathrooms were operating in safe and sanitary conditions. The hot water temperature in residents' bathrooms measured 106 degrees F. Resident’s bedrooms have sufficient lighting and furniture in good repair. The facility has operating telephone service and laundry equipment. The facility has posted in a common area, Ombudsman poster, facility license, evacuation exit plan and emergency telephone numbers. The facility has a visible fire alarm system; however, the Administrator stated she does not know how to test the fire alarm and does not have record of when the new alarm system was installed and/or tested. Deficiency cited.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

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: ADVENT LIFE CARE #2	FACILITY NUMBER: 366410284
	VISIT DATE: 02/15/2024

NARRATIVE

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Food Service: Facility has sufficient non-perishable and perishable food supply for residents in care. The refrigerator and freezer are operating in a healthful manner. Pesticides and other cleaning solutions were kept locked and stored away from food areas.

Care & Supervision: The facility has 24 hour/7 days a week care staff. Staff working have criminal record clearances or exemptions through the Department.

Record Review: Staff files reviewed were observed to be complete. Resident files reviewed were observed to be complete. Administrator’s certification expires on 7/8/24. The facility's liability insurance is current.

Medical Related Services: LPA observed medication was kept locked. LPA observed resident's a.m. and p.m. medication placed in a unlabeled plastic container. The Administrator stated that the medication had been refused by the resident. The Administrator stated that the medication has been discarded. Deficiency cited.

Based on observations and record review, Deficiencies are being cited per Title 22, Division 6 of The California Code of Regulations.

An exit interview was conducted where reports LIC809, LIC809-C, LIC809-D and LIC9102 were discussed. Copies of the 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: 02/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/15/2024 03:49 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: ADVENT LIFE CARE #2	FACILITY NUMBER: 366410284
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(5)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. 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 by storing residents am and pm medication in an unlabeled plastic cup; which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/16/2024
	Plan of Correction
1 2 3 4	The Licensee/Administrator shall submit to the licensing agency a statement of understanding on the above cited regulation by POC due date.

Type A

Section Cited

CCR

87203

Fire Safety - facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and 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 by The Administrator did not know how to test the fire alarm and does not have record of when the new alarm system was installed and/or tested; which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/16/2024
	Plan of Correction
1 2 3 4	The Licensee/Administrator shall submit proof of operating fire/carbon monoxide system 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: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

LIC809 (FAS) - (06/04)

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