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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366413072
Report Date: 09/20/2024
Date Signed: 09/20/2024 03:53:37 PM


Document Has Been Signed on 09/20/2024 03:53 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:VILLAS AT SAN BERNARDINOFACILITY NUMBER:
366413072
ADMINISTRATOR:CARLTON, KENYAFACILITY TYPE:
740
ADDRESS:2985 NORTH G STREETTELEPHONE:
(909) 883-7703
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92405
CAPACITY:97CENSUS: 92DATE:
09/20/2024
TYPE OF VISIT:Case Management - DeficienciesANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Administrator, Kenya CarltonTIME COMPLETED:
03:45 PM
NARRATIVE
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On 09/20/2024 at 09:20 AM, Licensing Program Analysts (LPAs) Renese Howell-Small and Melody Brown met with Administrator Kenya Carlton to initiate a Case Management Visit. The investigation consisted of observation, interviews, and a review of pertinent documentation.

During the facility visit today, 09/20/2024, LPAs Howell-Small and Brown toured the facility with Administrator Carlton and observed that Resident #4 (R4) with full bed rail and per interviews, observations and records review, R4 is not hospice and no Exemption Letter was submitted and approved by Community Care Licensing Division (CCLD). Deficiency will be issued. Also, LPAs Howell-Small and Brown observed multiple bottles of over-the-counter medications in Resident #3 (R3) room and per staff interviews and documents review, LPAs noted that R3’s on medication management and there are no doctors order for the multiple bottles of over-the-counter medications observed in R3’s room. Deficiency will be issued.

Moreover, LPAs Howell-Small and Brown audited five (5) residents’ medications and LPAs observed that six (6) of Resident #1 (R1) medications were not given as prescribed by R1’s physician as evidenced of R1’s Medication Administration Records (MARs) were blank for R1’s six (6) medications on 09/19/2024. Deficiency will be issued. In addition, LPAs observed Resident #5 (R5) Admission Agreement without the required signature of the Licensee or facility representative. Deficiency will be issued.

Furthermore, LPAs Howell-Small and Brown reviewed five (5) staff files and observed that Staff #5 (S5) did not complete the required First Aid/CPR Certification. Deficiency will be issued.

An exit interview was conducted where this report (LIC809), LIC809D and Appeal Rights were discussed and provided to Administrator Kenya Carlton.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2748
LICENSING EVALUATOR NAME: Renese Howell-SmallTELEPHONE: (951) 248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2024
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 4


Document Has Been Signed on 09/20/2024 03:53 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: VILLAS AT SAN BERNARDINO
FACILITY NUMBER: 366413072

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/21/2024
Section Cited
CCR
87608(a)(5)(B)

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87608 Postural Support (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall...(5) Under no circumstances shall postural supports include...(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.
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Licensee removed R4's full bed rail during the visit. Plan of Correction (POC) cleared.
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This requirement is not met as evidenced by: Based on observation, interview and record review the Licensee did not comply with the section cited above by permitting Resident #4 (R4) to have full bed rail which poses an immediate health, safety and personal rights to resident in care.
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Type A
09/21/2024
Section Cited
CCR87465(h)(1)(B)

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87465 Incidental Medical and Dental Care (h)The following requirements shall apply to medications which are... (1) Medications shall be centrally stored under the following circumstances: (B) Any medication is determined by the physician to be hazardous...
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Licensee immediately removed the multiple bottles of over-the-counter medications in R3's room. POC cleared. Also, Licensee conducted a medication training on all staff during the visit. POC cleared.
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This requirement is not met as evidenced by: Based on obervation, interview and record review the Licensee did not comply with the section cited above by not ensuring that all medications for Resident #3 (R3) were centrally stored as evidence of multiple bottles of over-the-counter medications observed in R3's room which poses an immediate health, safety and personal rights risk to resident in care.
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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) 836-2748
LICENSING EVALUATOR NAME: Renese Howell-SmallTELEPHONE: (951) 248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 09/20/2024 03:53 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: VILLAS AT SAN BERNARDINO
FACILITY NUMBER: 366413072

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/21/2024
Section Cited
CCR
87465(a)(4)

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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall... (4) The licensee shall assist residents with self-administered medications... This requirement is not met as evidenced by:
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Licensee conducted all staff training on CCR 87465(a)(4) during the visit. Plan of Correction (POC) cleared.
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Based on interview and records review,
the Licensee did not comply with the section cited above by not ensuring that staff are providing the required medication assistance to Resident #1 (R1) as prescribed by R1 physician which poses an immediate health, safety, or personal rights risk to persons in care.

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Type A
09/21/2024
Section Cited
CCR87411(c)(1)

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87411 Personnel Requirements – General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid...this requirement is not met as evidenced by:
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Licensee submitted proof of S5 completed certification for First Aid/CPR during the visit. POC cleared.
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Based on observation, interview, records review Licensee did not comply with the section cited above by not ensuring that Staff #5 (S5) completed the required First Aid/CPR training which poses an immediate health, safety and personal rights risk to resident in care.
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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) 836-2748
LICENSING EVALUATOR NAME: Renese Howell-SmallTELEPHONE: (951) 248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 09/20/2024 03:53 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: VILLAS AT SAN BERNARDINO
FACILITY NUMBER: 366413072

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/27/2024
Section Cited
CCR
87507(c)

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87507 Admission Agreements (c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident’s representative, if any and the licensee or the licensee’s designated representative. This requirement is not met as evidenced by:
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Licensee signed R5's Admission Agreement during the visit. Plan of Correction (POC) cleared.
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based on observation, interview and records review the Licensee did not comply with the section cited above by not signing the Admission Agreement for Resident #5 (R5) which poses a potential health, safety and personal rights risk to resident in care.
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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) 836-2748
LICENSING EVALUATOR NAME: Renese Howell-SmallTELEPHONE: (951) 248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4