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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366412237
Report Date: 02/14/2024
Date Signed: 02/14/2024 02:43:40 PM

Document Has Been Signed on 02/14/2024 02:43 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:LOVING CARE RANCHFACILITY NUMBER:
366412237
ADMINISTRATOR:TERESA G. DATUINFACILITY TYPE:
740
ADDRESS:25445 NATIONAL TRAIL HWYTELEPHONE:
(760) 245-4523
CITY:HELENDALESTATE: CAZIP CODE:
92342
CAPACITY: 18CENSUS: 10DATE:
02/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:08 AM
MET WITH:Lily Mayo- CaregiverTIME COMPLETED:
02:55 PM
NARRATIVE
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On 02/14/24, Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met caregiver, Lily Mayo and introduced self and stated purpose of the visit. LPA was informed that there are currently 10 residents in care who are in the facility.

The facility has 3 buildings: building #1 has 7 resident bedrooms, 1.5 resident bathrooms, 1 staff room, kitchen, dining area, entry room, living room, laundry room, backyard with 1 shed; building #2 has 3 resident bedrooms, 1 bathroom, entry room, kitchen, living room, laundry room, backyard with 1 shed; building # 3 has 2 resident bedrooms, 1 resident bathroom, kitchen and living room. LPA completed a walk through of facility and review of records.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 73 and 72 degrees fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected resident bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 120 and 114.1 degrees fahrenheit. The facility is equipped with carbon monoxide alarms, fire extinguisher and first aid kit. LPA observed 5 smoke detectors in building #1 not functioning, 1 smoke alarm in building #2 not functioning and the ceiling in the living room for building #2 broken. Deficiency issued. Posters such as; the ombudsman and emergency disaster plans were posted in a common area. LPA also observed cleaning supplies, toxins, sharps, and other dangerous items locked in cabinets made inaccessible to residents. There was a designated storage space for resident/staff files. Medications were observed secured and inaccessible to residents. LPA observed the medication moved from its original containers and placed on a small cups ready for the current day dispensing. Deficiency issued. There are no guns or ammunition in the facility. LPA observed the telephone in building #1 not functioning. Deficiency issued.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 8
Document Has Been Signed on 02/14/2024 02:43 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 02/14/2024 at 01:01 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: LOVING CARE RANCH
FACILITY NUMBER: 366412237

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the administrator did not comply with the section cited above in having an Infection Control Plan available for inspection which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2024
Plan of Correction
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Administrator stated that she will submit a complete and updated Infection Control Plan to LPA via email by POC due date.
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the administrator did not comply with the section cited above in having a copy of a current liability insurance for the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2024
Plan of Correction
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Administrator stated that she will submit a copy of a current liability insurance of the facility to the LPA via email 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:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024


LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 02/14/2024 02:43 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 02/14/2024 at 01:01 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: LOVING CARE RANCH
FACILITY NUMBER: 366412237

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the administrator did not comply with the section cited above in maintaining the facility in good repair like the 5 nonfunctioning smoke alarms in building #1 and 1 nonfunctioning smoke alarm and broken ceiling in building #2 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2024
Plan of Correction
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Administrator stated that she will have the maintenance person repair all the nonfunctioning smoke alarms and schedule an appointment for the ceiling to be repaired in the living room for building #2. Administrator will submit proof of repairs to LPA via email by POC due date.
Type B
Section Cited
HSC
1569.618(a)
Other Provisions
(a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the administrator did not comply with the section cited above in assigning an approved staff member to cover the facility while the administrator is on vacation which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2024
Plan of Correction
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Administrator stated that she will review HSC 1569.618(a) and submit a statement of understanding to LPA via email 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:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 02/14/2024 02:43 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 02/14/2024 at 01:01 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: LOVING CARE RANCH
FACILITY NUMBER: 366412237

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the administrator did not comply with the section cited above in having all complete staff files with required documents ready for inspection which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2024
Plan of Correction
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Administrator stated that she will submit the missing files and documents of staff to LPA via email by POC due date.
Type B
Section Cited
CCR
87412(d)
Personnel Records
(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the administrator did not comply with the section cited above in maintaining a nonexpired administrator's certificate ready for inspection which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2024
Plan of Correction
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Administrator stated that she will submit a copy of her nonexpired administrator's certificate to LPA via email 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:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 02/14/2024 02:43 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 02/14/2024 at 01:01 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: LOVING CARE RANCH
FACILITY NUMBER: 366412237

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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
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Based on observation, the administrator did not comply with the section cited above in keeping the residents medication in their original containers which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2024
Plan of Correction
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Administrator stated that she will host a training with all staff going over the regulation cited and submit proof of attendance to LPA via email by POC due date.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the administrator did not comply with the section cited above in conducting a drill at least quarterly for each shift which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2024
Plan of Correction
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Administrator stated that she will host a training with all staff going over the regulation cited and submit proof of attendance to LPA via email 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:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 02/14/2024 02:43 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 02/14/2024 at 01:01 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: LOVING CARE RANCH
FACILITY NUMBER: 366412237

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(d)
Other Provisions
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the administrator did not comply with the section cited above in reviewing and updating the emergency disaster plan which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2024
Plan of Correction
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Administrator stated that she will review and update the emergency disaster plan and submit a copy to LPA via email by POC due date.
Type B
Section Cited
CCR
87618(b)(3)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the administrator did not comply with the section cited above in posting oxygen signs on the residents bedrooms and a copy of the notice sent to the local fire department which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2024
Plan of Correction
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Administrator stated that she will review and complete the requirements needed for the regulation cited and submit a statement of understanding to LPA via email 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:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 02/14/2024 02:43 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 02/14/2024 at 01:05 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: LOVING CARE RANCH
FACILITY NUMBER: 366412237

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87311
Telephones
All facilities shall have telephone service on the premises. Facilities with a capacity of sixteen (16) or more persons shall be listed in the telephone directory under the name of the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the administrator did not comply with the section cited above in maintaining a functioning telephone landline which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2024
Plan of Correction
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Administrator stated that she will schedule an appointment with the phone company and have it repaired by POC due date and submit proof to LPA via email by POC due 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:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024


LIC809 (FAS) - (06/04)
Page: 7 of 8
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: LOVING CARE RANCH
FACILITY NUMBER: 366412237
VISIT DATE: 02/14/2024
NARRATIVE
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Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Dishes, cups, and utensils were also stored properly.

Yards/Outside: Three shaded patios, a gate with self-latching handle on the front and back side of the house and 2 sheds used for storage. All outdoor pathways were free of obstructions.

Record Review: LPA reviewed 5 resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA observed that there was one staff file missing and a missing cpr certification for another staff. Deficiency issued. LPA observed that the posted administrator's certificate expired on 7/13/22. Deficiency issued. The facility did not have the emergency drills log available for inspection. Deficiency issued. LPA observed that the administrator did not have an appointed and approved representative during their vacation absence. Deficiency issued. LPA observed that the posted emergency disaster plan has not been reviewed and updated since 5/14/18. Deficiency issued. LPA observed that the facility did not have a copy of the Infection Control Plan available for inspection. Deficiency issued. LPA observed that the residents bedrooms in building #1 did not have oxygen signs posted and the facility did not have record of the notice sent to the local fire department. Deficiency issued. LPA also observed that the administrator did not have a copy of the liability insurance available for inspection. Deficiency issued.

Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D and appeal rights were discussed and copies were provided to caregiver, Lily Mayo.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024
LIC809 (FAS) - (06/04)
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