366412117-9-26-2024-56-AS-BALN-D9GQG8-20240926120908

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366412117
Report Date: 09/26/2024
Date Signed: 09/26/2024 12:09:17 PM

Document Has Been Signed on 09/26/2024 12:09 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:	CAREGIVERS II		FACILITY NUMBER:	366412117
ADMINISTRATOR:	JAEWON KIM		FACILITY TYPE:	740
ADDRESS:	10945 TRENMAR LANE		TELEPHONE:	(909) 877-0850
CITY:	BLOOMINGTON	STATE: CA	ZIP CODE:	92316
CAPACITY:	6	CENSUS: 3	DATE:	09/26/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:48 AM
MET WITH:	Mr. Kilho Kim-caregiver		TIME COMPLETED:	12:15 PM

NARRATIVE

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Licensing Program Analyst (LPA’s) Bernadette Allen made an unannounced visit to the facility to conduct a required comprehensive annual inspection. LPA met with Mr. Kilho Kim -Caregiver who granted entry into the facility.

The facility is a Residential Care Facility for the Elderly (RCFE). License capacity of (6) clients with a current census of three (3). LPA Allen observed 1 staff, 2 residents, per Mr. Kim 1 resident was on a walk.

LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:

Physical Plant: LPA observed there are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected client bedrooms: they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately.

The hot water temperature tested within regulation at 104-124 degrees F. The facility is equipped with operating smoke detectors, carbon monoxide alarms and fully charge fire extinguishers. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area.

Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. Overall, the facility appeared to be clean, in good repair, and operating in safe conditions.

Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a variety of food available for clients. Dishes, cups, and utensils were also stored properly.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette Allen	TELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024

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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: CAREGIVERS II	FACILITY NUMBER: 366412117
	VISIT DATE: 09/26/2024

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Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPA reviewed three (3) residents files for admission agreements, updated physician reports, and Medication Administration Records (MAR’s). The 3 files provided for review during the visit were not current or incomplete. A citation was issued for not having current/complete files available for the residents in care.

LPA attempted to review 3 staff files that were not available for reviewed during the inspection. A citation was issued for not having staff files available for review.

Based on the observations made during today’s visit, two deficiencies were cited.

An exit interview was conducted, where this report LIC809, LIC809-C, LIC809-D and LIC9132 facility inspection checklist was discussed and provided to Mr. Kim caregiver at the conclusion of the visit with appeal rights.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette Allen	TELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/30/2024 10:23 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 09/27/2024 01:27 PM

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: CAREGIVERS II	FACILITY NUMBER: 366412117
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with ensuring that personnel records were maintained for each employee. LPA requested 3 staff files to review during the inspection, which were not available. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/03/2024
	Plan of Correction
1 2 3 4	Licensee has agreed to provide proof of completed files for all staff members. LPA provided the facility inspection checklist LIC9123.

Type B

Section Cited

CCR

87506(a)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with ensuring that each resident’s file was maintained. LPA requested files to review during the inspection, which were either incomplete or not current. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/03/2024
	Plan of Correction
1 2 3 4	The licensee has agreed to provide proof of completed files for all residents. LPA provided the facility inspection checklist LIC9123.

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: Bernadette Allen	TELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024

LIC809 (FAS) - (06/04)

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