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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425834
Report Date: 09/04/2024
Date Signed: 09/04/2024 03:25:04 PM


Document Has Been Signed on 09/04/2024 03:25 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:FOREMOST SENIOR CAMPUSFACILITY NUMBER:
366425834
ADMINISTRATOR:NIRUPAMA VANGALAFACILITY TYPE:
740
ADDRESS:17581 SULTANA STREETTELEPHONE:
(760) 244-5579
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY:96CENSUS: 84DATE:
09/04/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Danica TurnerTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Magda Malcore, Eldin Serrano, and Beena Singh initiated a case management visit based on observations during a Health and Safety check of the facility.

During a tour of the facility, LPAs observed in the kitchen, an uncovered gelatin tray and an uncovered pot filled with broth in the refrigerator. LPA's observed upon entering resident Wing #1, a strong odor. Staff stated that residents are changed; however some residents need be change more frequently. Staff stated that they will spray and sanitize the wing to eliminate the odor.

Based on LPAs observations, deficiencies are being cited in accordance with Title 22, of the California Code of Regulations.

An exit interview was conducted where this report was discussed. A copy of this report with Appeal Rights was provided to the Administrator at the conclusion of the visit.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:
DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 09/04/2024 03:25 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: FOREMOST SENIOR CAMPUS
FACILITY NUMBER: 366425834

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/05/2024
Section Cited
CCR
87555(b)(23)

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87555(b)The following food service requirements shall apply:(23)All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures.This requirement is not met at evidenced by:
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The Administrator stated that they will have an in-service training with kitchen staff regarding the regulation cited and provide documentation of training to Licensing by POC due date.
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based on LPAs observations the Licensee did not comply with the section cited above by LPAs observed in the kitchen, an uncovered gelatin tray and an uncovered pot filled with broth in the refrigerator; Which poses/posed an immediate health, safety, personal rights risk to persons in care.
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Type A
09/05/2024
Section Cited
CCR87625(b)(3)

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87625 (b) In addition to Section 87611,...the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement is not met at evidenced by:
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Staff cleared area of incontinence odors during LPAs visit. No futher action is required.
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based on LPAs observations the Licensee did not comply with the section cited above by LPA's observed upon entering resident Wing #1, a strong odor; which poses/posed an immediate health, safety, and personal rights risk to persons 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: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:
DATE: 09/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2