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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366412117
Report Date: 08/23/2023
Date Signed: 08/23/2023 04:02:44 PM


Document Has Been Signed on 08/23/2023 04:02 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:CAREGIVERS IIFACILITY NUMBER:
366412117
ADMINISTRATOR:JAEWON KIMFACILITY TYPE:
740
ADDRESS:10945 TRENMAR LANETELEPHONE:
(909) 877-0850
CITY:BLOOMINGTONSTATE: CAZIP CODE:
92316
CAPACITY:6CENSUS: 5DATE:
08/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Jumsoo Kim, LicenseeTIME COMPLETED:
04:00 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 Jumsoo Kim, Licensee, and discussed the purpose of the visit.
The facility is a Residential Care Facility for the Elderly (RCFE). License capacity of (6) clients with a current census of (5). Hospice waiver for (4). 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 and outdoor passageways are free of obstruction. The facility has sufficient lighting and is maintained at a comfortable temperature. Facility has no outdoor bodies of water. Backyard is fenced with self-latching gates. Facility has a covered outdoor patio area sufficient for clients in care.

LPA inspected the kitchen. The refrigerator and freezer are operating in a healthful manner. Hot water temperature is maintained at 105 degrees F. Facility has sufficient non-perishable and perishable food supply for clients in care. Facility has sufficient cups, plates, and utensils for client use. Facility food is stored in a safe and healthful manner.

LPA inspected client bedrooms. Bedrooms are equipped with beds, linens, nightstands, chairs, and sufficient storage space and lighting.

LPA inspected client bathrooms. Bathroom equipment is operating in a safe and sanitary condition. Bathroom hot water temperature tested at 105 degrees F.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2023
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: CAREGIVERS II
FACILITY NUMBER: 366412117
VISIT DATE: 08/23/2023
NARRATIVE
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LPA observed the facility is equipped with operating carbon monoxide alarms. Facility has operating telephone service on the premises. Posters such as personal rights, "Let-Us-NO", Ombudsman contact, evacuation plan and emergency phone numbers are posted in a common area. Facility has a complete first aid kit and emergency supplies. Facility has sufficient linen, towels and personal hygiene products for clients in care. Sharps, disinfectants, cleaning solutions, and toxins are kept locked and inaccessible to clients in care.

Client medications are properly labeled and kept in a safe and locked cabinet inaccessible to clients in care; However, LPA observed one client's daily routine medication was not administered as prescribed. Client 1 (C1) medication for 8/22/23 was observed still in the bubble packet. All client medications are being documented when administered.

All staff files reviewed had first aid certifications, fingerprint clearances/exemptions, health screenings training, personnel records.

LPA review of Client 2 (C2) and Client 3 (C3) records had admissions agreements, physician's reports, assessments; However, Facility did not have record of C1's medical/physician assessment documentation.

Deficiencies were cited during today's visit and proof of correction was discussed with the Licensee.

An exit interview was conducted, where reports (LIC809/809-D/LIC9102) were discussed and a copy of reports with appeal rights was provided to the Licensee at the conclusion of the visit.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023
LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 08/23/2023 04:02 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: CAREGIVERS II
FACILITY NUMBER: 366412117

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations, the licensee did not comply with the section cited above by Client 1 (C1) daily routine (am) medication was not administered on 8/22/23. The medication was observed still in the bubble packet, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/24/2023
Plan of Correction
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Administrator/Licensee shall submit a statement of understanding on the cited regulation by POC 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: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2023
LIC809 (FAS) - (06/04)
Page: 3 of 8


Document Has Been Signed on 08/23/2023 04:02 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: CAREGIVERS II
FACILITY NUMBER: 366412117

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review, the licensee did not comply with the section cited above by facility did not have record of Client 1 (C1) pre-appraisal, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/05/2023
Plan of Correction
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Licensee/Administrator shall submit to the licensing agency proof of appraisal by POC date.
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA file review, the licensee did not comply with the section cited above facility did not have record of Client 1 (C1) medical/physician assessment documentation, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/05/2023
Plan of Correction
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Licensee stated that hospice has clients physician's report. Administrator/Licensee shall provide proof of physician's report or physician's assessment by POC 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 ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2023
LIC809 (FAS) - (06/04)
Page: 4 of 8


Document Has Been Signed on 08/23/2023 04:02 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: CAREGIVERS II
FACILITY NUMBER: 366412117

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(c)(3)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA records review, the licensee did not comply with the section cited above by facility does not maintain a record of date and time of medication taken for clients unable to determine their need for medication, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/05/2023
Plan of Correction
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Licensee/Administrator shall document when medication is taken and provide a statement of understanding on the above cited regulation by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2023
LIC809 (FAS) - (06/04)
Page: 5 of 8