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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425834
Report Date: 07/11/2024
Date Signed: 07/11/2024 04:44:03 PM


Document Has Been Signed on 07/11/2024 04:44 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: 78DATE:
07/11/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Danica Turner- AdministratorTIME COMPLETED:
04:54 PM
NARRATIVE
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Licensing Program Analyst (LPA), Michelle Echeverria arrived at the facility and conducted an unannounced Case Management Visit for health and safety. This case management visit is in response to a report received at Community Care Licensing about the air conditioning not working in Wing 2 of the facility. LPA was greeted by staff, Shilo Fenio at front door and granted entrance. LPA introduced self and stated purpose of the visit. Staff, Shilo stated that administrator, Danica Turner was not present due to running an errand and would be back shortly. LPA later met with Administrator, Danica Turner and introduced self and stated purpose of the visit.

During today's visit, LPA conducted observations, a health and safety check and interviews with staff and residents. LPA observed that the central air conditioning unit in wing 2 was not working. LPA observed that 7 out of 12 bedrooms had portable air conditioning units and the other 5 occupied bedrooms with residents did not have portable air conditioning units. Administrator stated that the central air conditioning unit broke down on Monday, July 8, 2024 and repair began on Tuesday and was not completed due to a missing part being delayed. Administrator stated that she did not have records showing the air conditioner maintenance request and delayed status. LPA observed that an excessive heat warning remains in effect and is currently affecting the facility's location area.

Deficiency was observed during this visit. An exit interview was conducted where this report LIC809, LIC809D and appeal rights were discussed and given to Administrator, Danica Turner.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle EcheverriaTELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2024
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 07/11/2024 04:44 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: 07/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/12/2024
Section Cited
CCR
87303(a)

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87303(a) Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and.. and visitors. This requirement is not met as evidenced by:
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Administrator stated that she will purchase and install portable air conditioning units to the 5 bedrooms that do not have one. Administrator stated that she will send picture of receipts and pictures on installed air conditioning units to LPA via email by POC due date.
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Based on observation and interview, the administrator did not comply with the section cited above in maintaining the air conditioning unit in wing 2 in good repair which poses an immediate health, safety or 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: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle EcheverriaTELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2024
LIC809 (FAS) - (06/04)
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