366424158-5-10-2024-56-AS-MMAE-D55T3C-20240510142206

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366424158
Report Date: 05/10/2024
Date Signed: 05/10/2024 02:22:18 PM

Document Has Been Signed on 05/10/2024 02:22 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:	YUCAIPA VALLEY BOARD & CARE		FACILITY NUMBER:	366424158
ADMINISTRATOR:	ANIKO A. BARLOW		FACILITY TYPE:	740
ADDRESS:	33176 COLORADO STREET		TELEPHONE:	(909) 795-3065
CITY:	YUCAIPA	STATE: CA	ZIP CODE:	92399
CAPACITY:	5	CENSUS: 3	DATE:	05/10/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:05 AM
MET WITH:	Aniko Barlow - Administrator		TIME COMPLETED:	02:30 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 Aniko Barlow, Administrator, and discussed the purpose of the visit.

The facility is a Residential Care Facility for the Elderly (RCFE) with a license capacity of (5) and a current census of (3) residents in care. LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:

Physical Plant/Environment: Indoor passageways are free of obstruction. The facility has no swimming pools or similar bodies of water. Outdoor shaded area is sufficient for resident activities and is enclosed with a self-latching gate. The facility has sufficient lighting and is maintained at a comfortable temperature. Resident’s showers, toilets, and hand washing areas were operating in a safe and sanitary condition. The hot water temperature in residents' bathrooms measured 111- and 115-degrees F. Four (4) resident’s bedrooms had beds, bed linen, chairs, nightstands, and sufficient storage space and lighting. The facility had operating carbon monoxide/fire alarms, laundry equipment, and telephone service. The facility has sufficient bed linen, towels, and personal hygiene items for residents. The facility has posted in a common area, Community Care Licensing complaint poster, Ombudsman poster, facility license, and disaster evacuation plan. Sharps, disinfectants, and cleaning solutions were kept in a locked cabinet.

Care & Supervision: Facility has 24-hour, 7 days a week care staff. Facility staff has current CPR/first aid training.

Medical Related Services: Resident’s medications are labeled and centrally stored in a locked cabinet. The facility has a complete first aid kit with manual.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024

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: YUCAIPA VALLEY BOARD & CARE	FACILITY NUMBER: 366424158
	VISIT DATE: 05/10/2024

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Food Service: The facility kitchen and dining areas are maintained clean. The facility has sufficient non-perishable and perishable food supply for residents in care. The facility has a menu posted in the kitchen area.

Record Review: Three (3) staff files reviewed were observed to be complete. Three (3) resident files reviewed were observed to be complete. The facility has current liability insurance, emergency disaster plan and infection control plan on file for review.

Based on observations and record review, the following deficiencies are being cited per Title 22, of The California Code of Regulations and per Health and Safety Code:

The Licensee did not maintain a current quarterly emergency drill on file. The last fire drill conducted was on 8/4/23.
The Licensee did not maintain the backyard free observation as overgrown scrubs/foliage blocked passageway.
The Licensee did not maintain an approved Hospice waiver increase on file. The facility has an approved Hospice waiver for two (2) and currently has three (3) residents receiving Hospice Care. During the visit, LPA contacted the regional office and no request was found for a Hospice waiver increase.

This report and LIC809-D was reviewed with the Administrator and a copies with Appeal Rights was provided to the Administrator and 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: 05/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/10/2024 02:22 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: YUCAIPA VALLEY BOARD & CARE	FACILITY NUMBER: 366424158
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(d)(6)

Personal Accommodations and Services

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observations, the licensee did not comply with the section cited above by overgrown scrubs/foliage blocking passageway, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/24/2024
	Plan of Correction
1 2 3 4	The Licensing shall submit to the licensing agency documentation of cleared outdoor passageway by POC due date.

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA record review, the licensee did not maintain a current drill on file, the last drill conducted was 8/4/23, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/24/2024
	Plan of Correction
1 2 3 4	The Licensee shall submit to the Licensing Agency documentation of current drill conducted with staff by POC due date.

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: 05/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/10/2024 02:22 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: YUCAIPA VALLEY BOARD & CARE	FACILITY NUMBER: 366424158
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Hospice Care for Terminally Ill Residents


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Type B

Section Cited

CCR

87633(a)(1)

Hospice Care for Terminally Ill Residents

(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility, when all of the following conditions are met: (1) The licensee has received a hospice care waiver from the department. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA record review, the licensee did not comply with the section cited above by not maintaining an approved hospice waiver increase on file; which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/24/2024
	Plan of Correction
1 2 3 4	The Licensee shall submit to the Licensing Agency a request for hospice increase waiver with documentation required under regulation 87632 Hospice Care Waiver by POC due date.

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: 05/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024

LIC809 (FAS) - (06/04)

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