366425610-1-30-2023-56-AS-ACON-CNL2KP-20230130162817

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366425610
Report Date: 01/30/2023
Date Signed: 01/30/2023 04:33:08 PM

Document Has Been Signed on 01/30/2023 04:33 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:	EXCELCARE		FACILITY NUMBER:	366425610
ADMINISTRATOR:	ANDERSON, DORRIS		FACILITY TYPE:	740
ADDRESS:	11400 POPLAR STREET		TELEPHONE:	(909) 796-4553
CITY:	LOMA LINDA	STATE: CA	ZIP CODE:	92354
CAPACITY:	10	CENSUS: 10	DATE:	01/30/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Dorris Anderson, Administrator		TIME COMPLETED:	04:30 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, Amber Coleman arrived at the Excel Care Facility unannounced to conduct an Annual Inspection with a focus on infection control. LPA introduced self and stated the purpose of the visit. LPA met with Dorris Anderson, Administrator. LPA signed in at the facility's COVID station. At the COVID station, LPA observed hand hygiene, PPE and signs for infection control posted. LPA was provided a space to work before completing walk through of facility. Administrator reports at this time there are no residents or staff suspected of COVID symptoms. LPA observed serval staff members also wearing proper PPE. Current census is 10. During the inspection, LPA interviewed Administrator pertaining to the facility's infection control measures and other health and safety concerns. LPA observed necessary signs posted in the facility, including signs related to COVID-19, which were in accordance with the Department's guidelines. Administrator stated that the facility is equipped with sufficient PPE, hand hygiene supplies, and sufficient cleaning/disinfecting provisions. Extra supplies were observed in the secured facility laundry room. 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 facility's infection control measures. The facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolation of residents, and properly caring for residents with COVID-19 positive results and/or exposures. The facility also has a plan in place to monitor residents regularly for any changes in condition and to subsequently notify the resident's physician and emergency personnel in the event the resident presents any COVID-19 symptoms. *Please See LIC809C*

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2023

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: EXCELCARE	FACILITY NUMBER: 366425610
	VISIT DATE: 01/30/2023

NARRATIVE

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At approximately 2:30pm LPA observed room #6. Room #6 is currently occupied by 1 resident. LPA observed the resident lying on the bed. The bed consisted of 2 twin sized box springs and 2 twin sized mattresses stacked on top of one another. Administrator explained that resident #1 is at risk for falls due to a medical/behavioral condition. The bedframe and headboard were removed to prevent injury.

At approximately 2:40pm, LPA completed walk through of the kitchen area to make view of the facility's food supply. LPA observed 5 cans, of 5 cans 4 cans had expired.

Inspection Tool was utilized, Mitigation plan was reviewed. Facility was further inspected, deficiencies issued. A exit interview was conducted and a copy of this report LIC809C, LIC809D, appeal rights were provided to Administrator Dorris Anderson.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/30/2023 04:33 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: EXCELCARE	FACILITY NUMBER: 366425610
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

877555(b)(8)

(8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation of the facility food pantry on 1/30/23's visit the licensee did not comply with the section cited above in 4 out of 5 food cans being expired; which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/28/2023
	Plan of Correction
1 2 3 4	Licensee agrees to go through all kitchen pantries and cabinets to remove and can goods/foods that have been expired.

Type B

Section Cited

HSC

87307(a)(3)(a)

Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (A) A bed for each resident, except that married couples may be provided with one appropriate sized bed. Each bed shall be equipped with good springs, a clean and comfortable mattress, available pillow(s) and lightweight warm bedding. Fillings and covers for mattresses and pillows shall be flame retardant. Rubber sheeting shall be provided when necessary. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation during visit on 1/30/23 of Room #6. Resident observed sleeping on 2 mattresses and 2 box springs stacked on top of one another; the licensee did not comply with the section cited above in not providing resident with furniture to accommodate the resident which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/28/2023
	Plan of Correction
1 2 3 4	Licensee agrees to request proper documentation to show support of the resident being a fall risk. If any, demonstrate the need to remove the required furniture for the resident's safety. If such documentation cannot be obtained, Licensee will place all necessary furniture to accommodate the requirement and the needs of the resident.

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	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2023

LIC809 (FAS) - (06/04)

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