366423587-5-18-2022-56-AS-RGAR-CEJSXZ-20220518141646

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366423587
Report Date: 05/18/2022
Date Signed: 05/18/2022 02:16:57 PM

Document Has Been Signed on 05/18/2022 02:16 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:	SARAH JANE GUEST HOME		FACILITY NUMBER:	366423587
ADMINISTRATOR:	MOLANO, NINA		FACILITY TYPE:	740
ADDRESS:	25488 NICKS AVENUE		TELEPHONE:	(909) 799-7501
CITY:	LOMA LINDA	STATE: CA	ZIP CODE:	92354
CAPACITY:	6	CENSUS: 2	DATE:	05/18/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:06 PM
MET WITH:	Nina Molano- Administrator		TIME COMPLETED:	02:27 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. LPA Gardner met with Administrator Nina Molano who confirmed that there are currently no cases/exposures of COVID-19 within the facility. At the time of visit there were three (3) staff and two (2) residents present. LPA Gardner toured the facility inside and out and went over COVID-19 best practices for infection control and prevention with Nina Molano. The facility has a COVID-19 mitigation plan on file that follows Community Care Licensing Division guidelines for the safety and care of the residents. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the proper use and disposal of PPE. Residents have hand sanitizer available to them and the bathrooms were stocked with hand soap and paper towels. LPA Gardner observed the facility to have multiple postings throughout the facility for cough etiquette, proper hand washing procedure, and social distancing. LPA Gardner requested to inspect the facility's Personal Protective Equipment (PPE) supply, which was located at the in the hall cabinet. The facility has a full thirty (30) day supply of PPE items such as gloves, face shields, gowns, surgical masks, N95 masks, disinfectant, and hand sanitizer supply. LPA Gardner inquired as to if staff have been fit tested for N95 masks and was informed their staff have not been N95 fit tested yet. LPA Gardner will be issuing a Technical Assistance Advisory Note during today's inspection for staff not being fit tested for N95 masks. All residents and staff are practicing all other COVID-19 precautions, which minimize the risk of them contracting COVID-19.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022

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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Document Has Been Signed on 05/18/2022 02:16 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: SARAH JANE GUEST HOME	FACILITY NUMBER: 366423587
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(5)

87465. Incidental Medical and Dental Care.(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
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above by pre prepping AM and PM medications for residents for seven days in plastic container cups. The plastic container cups are not the original containers the medication came in from the pharmacy. This poses a potential health, safety, or personal rights risk to the persons in care.
	POC Due Date: 05/23/2022
	Plan of Correction
1 2 3 4	The licensee has agreed to read regulation 87465 entirely and send LPA a self certify letter that the regulation was read and understood. The licensee has agreed to store the resident's medications in the original containers from the pharmacy.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 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	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022

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: SARAH JANE GUEST HOME	FACILITY NUMBER: 366423587
	VISIT DATE: 05/18/2022

NARRATIVE

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During today’s visit, LPA Gardner found that the facility is pre prepping the resident’s AM and PM medications a week in advance (7 days) in plastic container cups. The medications are not being stored in the original containers from the pharmacy. This poses a potential health, safety, or personal rights risk to the persons in care. The facility will be issued a citation for not storing the resident’s medications properly.

Based on the observations made during today’s visit, one (1) type B deficiency was cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report was discussed and provided to Nina Molano along with a copy of the TA Advisory Note, LIC-809D, and the appeal rights.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022

LIC809 (FAS) - (06/04)

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