366410686-2-13-2024-56-AS-ACON-D2EVC3-20240213151827

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366410686
Report Date: 02/13/2024
Date Signed: 02/13/2024 03:18:42 PM

Document Has Been Signed on 02/13/2024 03:18 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:	ALTA LOMA BOARD AND CARE		FACILITY NUMBER:	366410686
ADMINISTRATOR:	G CAYANAN/F CAYANAN		FACILITY TYPE:	740
ADDRESS:	6368 MOONSTONE AVE		TELEPHONE:	(909) 941-8459
CITY:	RANCHO CUCAMONGA	STATE: CA	ZIP CODE:	91701
CAPACITY:	6	CENSUS: 5	DATE:	02/13/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:50 PM
MET WITH:	Lani Trinidad, Caregiver & Gina Cayanan, Administrator		TIME COMPLETED:	03:20 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, Amber Coleman, (LPA) arrived unannounced tot the Alta Loma Board & Care, Residential Care Facility for the Elderly, to conduct the Annual Inspection. LPA was greeted and granted entry by Caregiver, Lani Trinidad. Ms. Trinidad informed LPA that the Administrator had just stepped out and will return shortly. LPA thanked Ms. Trinidad and was provided a space to work. Administrator, Gina Cayanan arrived later during the visit who accompanied LPA on a tour of the facility. The facility is a residential Home comprised of 5 bedrooms, 2 bathrooms, kitchen, dining room, Living Room, Den (Staff Office/Lobby), backyard and attached garage. LPA conducted a general inspection, which include, but was not limited to the following: Physical Plant - The facility is approved for 6 residents. Five, (5) non-ambulatory residents and one, (1) bedridden resident. The facility maintains both a Dementia and Bedridden Care Plan. LPA observed the facility maintained at 73 degrees Fahrenheit - comfortable temperature. Interior pathways were free of clutter and obstructions. LPA inspected 4 resident rooms. Each room contained all required furniture such as sufficient storage space, lighting, bed with proper linens, night stands and seating. There are 2 bathrooms. Each bathroom was equipped with handrails, non-slip grip rugs, and adequate amounts of hand hygiene and paper supplies. LPA observed a fully charged fire extinguisher - last inspected February 2024. The facility is also equipped with operable fire and carbon monoxide alarms throughout the facility. Tested during visit. Food Service: LPA observed the kitchen. Non-perishable and perishable food supply is sufficient for number of residents in care. Food items observed: canned goods in good standing, meats, fresh fruit, milk, eggs and bread. Facility maintains a posted food menu. Sufficient amounts of dishes, cups, and utensils were also observed and stored properly. Chemicals, Cleaning Supplies, Medications and Sharps/Dangerous Objects were observed in the kitchen to be kept in secure places inaccessible to residents in care. Water Temperature measured in the kitchen found within regulatory limits. -Please see LIC809-C

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024

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: ALTA LOMA BOARD AND CARE	FACILITY NUMBER: 366410686
	VISIT DATE: 02/13/2024

NARRATIVE

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Care & Supervision: Facility has sufficient care staff for coverage 7 days a week and 24 hours a day. The facility maintains a staff room available to those who may need it. LPA reviewed Staff Records and observed the following: Criminal Record/Fingerprint Clearances, Health Screenings, Personnel Records. Staff Training included: Dementia Care, First Aid/CPR, Activities of Daily Living, Fall Safety, Medication Management, and Disaster Training.

Posters such as: Resident/Personal Rights, Resident Council, See Something / Say Something, Facility Sketch with disaster/evacuation plans, Facility License and Long Term Care Ombudsman were posted in a prominent place.

Record Review: Facility Records, Staff and Resident files are maintained securely in the Staff Office Area. LPA reviewed resident files for Admission Agreements, Updated Physician Reports, and Needs and Services plans. LPA observed that resident Physician's Reports will need to be updated to compliance. Administrator has began process to obtain updated documents for residents in care.

Based on observations and review of records, a deficiency will be cited per Title 22, California Code of Regulations to address documentation. An exit interview was conducted, this report was reviewed, discussed and provided to Facility Representative.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/13/2024 03:18 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: ALTA LOMA BOARD AND CARE	FACILITY NUMBER: 366410686
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87456(a)(3)

Evaluation of Suitability for Admission

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (3) Obtain and evaluate a recent medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on review of records and staff interview the licensee did not comply with the section cited above by not ensuring all residents in care maintained an updated Physician's Report (LIC602) which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/13/2024
	Plan of Correction
1 2 3 4	Administrator/Licensee agrees to assist the resident/resident families in making and keeping an appointment with their Primary Care Physician to obtain an updated Physician's Report (LIC602). Administrator also agrees to submit verification to the Community Care Licensing Office within 30 business days.

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: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024

LIC809 (FAS) - (06/04)

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