366423587-8-18-2023-56-AS-MMAE-CUTV3R-20230818160510

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366423587
Report Date: 08/18/2023
Date Signed: 08/18/2023 04:05:19 PM

Document Has Been Signed on 08/18/2023 04:05 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:	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: 3	DATE:	08/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:25 PM
MET WITH:	Nina Molano, Administrator		TIME COMPLETED:	03:45 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) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Nina Molano, Administrator, and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE). License capacity of (6) clients with a current census of (3). Hospice waiver for (2). LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: LPA inspected the facility inside and out. Indoor and outdoor passageways are free of obstruction. The facility has sufficient lighting and is maintained at a comfortable temperature. Facility has sufficient indoor and outdoor space for client use. Facility outdoor pool is empty and observed secured with a locked fence inaccessible to clients in care. Facility backyard has a covered outdoor patio area sufficient for clients. LPA inspected the kitchen. The refrigerator and freezers are maintained in a safe and healthful manner. Hot water temperature is maintained with regulations. Facility has sufficient non-perishable and perishable food supply for the number of clients in care. Facility has sufficient cups, plates, and utensils for client in care. LPA inspected client bedrooms. Bedrooms are equipped with beds, linen, nightstands, chairs, storage space and sufficient lighting. LPA inspected client bathrooms. Bathrooms are operating in a safe and sanitary condition. Bathroom hot water temperatures tested within regulations.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023

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: SARAH JANE GUEST HOME	FACILITY NUMBER: 366423587
	VISIT DATE: 08/18/2023

NARRATIVE

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LPA observed the facility is equipped with operating carbon monoxide alarms. Facility has operating telephone service on the premises. Fireplace is adequately screened. Posters such as Ombudsman contact, "See Something, Say Something" contact, emergency plan and phone numbers are posted in a common area. Facility has sufficient supply of linen, towels, and personal hygiene products. Disinfectants, cleaning solutions, toxins, sharps are kept locked and inaccessible to clients in care.

Client medications are kept in a safe and locked cabinet inaccessible to clients in care. Facility did not have documentation of when prescribed medication is being administered to clients. Deficiency cited.

All staff files reviewed had first aid certifications, fingerprint clearances/exemptions, health screenings, employee rights and personnel records.

All client records reviewed had admissions agreements, physician's reports, personal rights statements, safeguarded resources records.

An exit interview was conducted, where reports (LIC809/LIC809D) were discussed and a copy of reports with appeal rights was provided to at the conclusion of the visit.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/18/2023 04:05 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SARAH JANE GUEST HOME	FACILITY NUMBER: 366423587
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(c)(3)

Incidental Medical and Dental Care Services

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation and record review, the licensee did not comply with the section cited above by facility did not have documentation of when prescribed medication is being administered to clients, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/21/2023
	Plan of Correction
1 2 3 4	Administrator/Licensee to submit proof of in-service staff training of the importance of documenting when medication is given to clients and include regulation cited by POC date.

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: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023

LIC809 (FAS) - (06/04)

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