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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366412237
Report Date: 12/11/2024
Date Signed: 12/11/2024 03:58:47 PM

Document Has Been Signed on 12/11/2024 03:58 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/
DIRECTOR:		TERESA G. DATUINFACILITY TYPE:
740
ADDRESS:25445 NATIONAL TRAIL HWYTELEPHONE:
(760) 245-4523
CITY:HELENDALESTATE: CAZIP CODE:
92342
CAPACITY: 18CENSUS: 9DATE:
12/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Maria Teresa DatuinTIME VISIT/
INSPECTION 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 Maria "Teresa" Datuin, Administrator, and discussed the purpose of the visit.

The facility is a three (3) building, Residential Care Facility for the Elderly (RCFE) with a license capacity of (18) and a current census of (9) residents in care and hospice waiver for (4). LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:

Physical Plant/Environment: Indoor and outdoor passageways are free of obstruction. The facility has no swimming pools or similar bodies of water. Outdoor activity area is gated and sufficient for client activities. The facility has sufficient lighting and is maintained at a 71 degrees F. The facility has operating carbon monoxide/smoke alarms, laundry equipment, signal system and telephone service. Resident 3 1/2 bathroom equipment were operating in a safe and sanitary condition. The hot water temperature in residents' bathrooms measured 119 degrees F. LPA observed a clorox cleaner kept unlocked in resident's bathroom. Staff removed the cleaner. Six (6) resident bedrooms were inspected. LPA observed full bedrails in resident #1 (R1) and resident#2 (R2); R1 and R2 are not receiving hospice care. LPA observed half bedrails in resident # 4 (R4) and resident #5 (R5). The Administrator stated the bed rails are utilized for fall prevention; However this is no documentation of physician's orders approving R4's and R5's bedrails. LPA observed staff utilizing part of R1's room area for facility storage use. The facility has posted in a common area, Ombudsman poster, Personal Rights, disaster evacuation plan and emergency telephone numbers.
Food Service: Facility's (3) kitchen areas were maintained clean. The facility has sufficient non-perishable and perishable food supply for residents in care. The facility has posted a weekly menu. In building #1, LPA observed an unlocked kitchen cabinet with cleaning supplies and disinfectants. LPA observed staff attempting to lock the cabinet; however the lock was not working properly. Staff removed the supplies and disinfectants and placed them in a locked medication room. Staff then fixed the locked that was not working properly.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2024
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: LOVING CARE RANCH
FACILITY NUMBER: 366412237
VISIT DATE: 12/11/2024
NARRATIVE
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Medical Related Services: In building #2, LPA observed an unlocked medication closet were resident's medications were stored and accessible to residents in care. Staff locked the cabinet.

Record Review: The facility has a disaster plan and infection control plan for review. Staff files were reviewed for health screening, personnel record (LIC501), criminal record clearances, job training and firstaid/CPR certification. Resident files were reviewed for admission's agreement, preplacement appraisals, personal rights and medical assessments. LPA observed R1's medication was placed in two (2) daily pillboxes. Administrator stated that the resident's spouse wants them to keep them in the pill box. LPA observed Resident #3 (R3's) AM medication from day 1 through day 11 was still in the bubble pack. The Administrator stated that the resident only wants to take the pill once a day; however this is no documentation of resident refusal and no documentation of staff contacting R3's physician of the refusal. The prescription label shows medication to be given twice daily. LPA also observed R3's was out one of their daily medication. The Administrator stated the medication should arrive later today or tomorrow. R3's physicians report/assessment (LIC602) shows resident takes insulin injection pen and uses a foley catheter. Administrator stated that the resident no longer utilizes these items. Interview with resident #3 reveals they are no longer using insulin injections and catheter. Administrator stated she will have an updated medical report conducted. LPA requested a staff schedule from the Administrator; a schedule showing staff hours was not available for review.

During today's visit, Deficiencies were cited and technical advisories were issued in accordance with Title 22 of the California Code of Regulations.

An exit interview was conducted where this report was discussed. Copies with appeal rights were provided to the Administrator at the conclusion of the visit.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
LIC809 (FAS) - (06/04)
Page: 2 of 13
Document Has Been Signed on 12/11/2024 03:58 PM - It Cannot Be Edited


Created By: Magda Malcore On 12/11/2024 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: 12/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observed, the licensee did not comply with the section cited above by not maintaining cleaning supplies and disinfectants locked and inaccessible to residents in care; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2024
Plan of Correction
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Staff removed the cleaning supplies and placed them in a locked room. No further action required.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA obervations, the licensee did not comply with the section cited above by not maintaining resident's medications in building #2 locked;which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2024
Plan of Correction
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Staff locked medication closet. No further action required.
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
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2024


LIC809 (FAS) - (06/04)
Page: 3 of 13
Document Has Been Signed on 12/11/2024 03:58 PM - It Cannot Be Edited


Created By: Magda Malcore On 12/11/2024 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: 12/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(5)
(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 LPA observations, the licensee did not comply with the section cited above by maintaining resident's medication in pill boxes; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2024
Plan of Correction
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The Licensee/Administrator shall submit a statement of understanding the regulation cited.
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 Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2024


LIC809 (FAS) - (06/04)
Page: 4 of 13
Document Has Been Signed on 12/11/2024 03:58 PM - It Cannot Be Edited


Created By: Magda Malcore On 12/11/2024 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: 12/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(e)
(e) In all cases, personnel records shall demonstrate adequate staff coverage necessary for facility operation by documenting the hours actually worked.

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 not maintaining a staff schedule with staff hours for review; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/10/2025
Plan of Correction
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The Licensee/Administrator shall submit to the Licensing agency a staff schedule by plan of correction date.
Type B
Section Cited
CCR
87608(a)(5)(B)
Postural Supports (a) based on the individual's preadmission appraisal...the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (B)Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above by having residents in full bedrails who are not under hospice care; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/10/2025
Plan of Correction
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The Licensee/Administrator stated they will request a written physician orders for bed rail approval.
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
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2024


LIC809 (FAS) - (06/04)
Page: 5 of 13
Document Has Been Signed on 12/11/2024 03:58 PM - It Cannot Be Edited


Created By: Magda Malcore On 12/11/2024 at 02:36 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: 12/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(A)
Postural Supports (a) based on the individual's preadmission appraisal...the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

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 utilizing half bed for other purposes other than mobility without a physician's order; which poses/posed a potential health, safety or personal rights risk to persons in care.,
POC Due Date: 01/10/2025
Plan of Correction
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The Licensee/Administrator stated that they will provide physician's approval for half bed rails and submit to licensing 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:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2024


LIC809 (FAS) - (06/04)
Page: 11 of 13
Document Has Been Signed on 12/11/2024 03:58 PM - It Cannot Be Edited


Created By: Magda Malcore On 12/11/2024 at 02:44 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: 12/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.1(a)(13)
Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights(13)To have access to individual storage space for private use.

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 storing facility supplies in R1's private room; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2024
Plan of Correction
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The Licensee/Administator shall have the storage items that do not belong to R1 removed from R1's closet by Plan of Correction date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2024


LIC809 (FAS) - (06/04)
Page: 12 of 13
Document Has Been Signed on 12/11/2024 03:58 PM - It Cannot Be Edited


Created By: Magda Malcore On 12/11/2024 at 03:13 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: 12/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.


This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA observation, the licensee did not comply with the section cited above by not maintaining an updated medical assessment reflecting R3's change in condition; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/10/2025
Plan of Correction
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2
3
4
The Licensee/Administrator shall provide an updated medical assessment to the Licensing Agency by Plan of correction date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
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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:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2024


LIC809 (FAS) - (06/04)
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