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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366423875
Report Date: 03/04/2024
Date Signed: 03/04/2024 02:21:43 PM

Document Has Been Signed on 03/04/2024 02:21 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:MISSION OF LOVE IIFACILITY NUMBER:
366423875
ADMINISTRATOR:JESSICA V. VILLANUEVAFACILITY TYPE:
740
ADDRESS:11991 7TH AVENUETELEPHONE:
(760) 947-5211
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY: 14CENSUS: 14DATE:
03/04/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:54 AM
MET WITH:JEssica VillanuevaTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Anna Bueno annd Bianca Wolcott conducted an unannounced visit to the facility for the investigation of complaint number: 56-AS-20240228135949. LPAs met with licensee Jessica Villanueva who was advised of the purpose of today's visit

During today's visit, LPAs interviewed relevant parties, made facility observations, and reviewed records. It was observed that Resident 1 was restrained to their bed with a sheet. Staff interviewed stated that the sheet is used for prevention of falling when Resident 1 is upright. The sheet covered Resident 1 through their top forearm and tied to the corner of a bed rail loosely. This pose as an immediate health and safety risk to resident in care. Refer to LIC 809D for deficiency cited.

Resident 1 was immediately released from the restraint. LPAs did not observe any bruising or skin discoloration on Resident 1's forearms during the use of the sheet or any restraint. An exit interview was conducted where this report, LIC809-D, and appeal rights were discussed with and provided to Licensee.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Bianca Wolcott
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2024
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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Document Has Been Signed on 03/04/2024 02:21 PM - It Cannot Be Edited


Created By: Bianca Wolcott On 03/04/2024 at 02:05 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: MISSION OF LOVE II
FACILITY NUMBER: 366423875

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/04/2024
Section Cited

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(a) Based on the individual's preadmission appraisal, and subsequent changes to that 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.
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This requirement was not met as evidenced by:

Resident 1 was observed tied to their rail with a sheet. This poses an immediate health and safety risk to residents 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:Nedra Brown
LICENSING EVALUATOR NAME:Bianca Wolcott
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2024


LIC809 (FAS) - (06/04)
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