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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426081
Report Date: 02/28/2024
Date Signed: 02/28/2024 03:50:22 PM


Document Has Been Signed on 02/28/2024 03:50 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507



FACILITY NAME:COMFORT HOME 2FACILITY NUMBER:
366426081
ADMINISTRATOR:LAL, HARISH K.FACILITY TYPE:
740
ADDRESS:7092 PROVIDENCE WAYTELEPHONE:
(909) 371-3427
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY:6CENSUS: 5DATE:
02/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Licensee Sushma LalTIME COMPLETED:
04:00 PM
NARRATIVE
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On 02/28/2024 at 09:30 AM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Brown met with a staff and was granted entry to the facility. Licensee Sushma Lal was contacted and arrived at the facility during the visit. At the time of the visit there's (1) staff present, and five (5) residents present.

The facility is a five (5) bedroom, two and a half (2 1/2) bathrooms with a kitchen/dining area, and living room and garage. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) of which two (2) can be ambulatory residents and four (4) can be non-ambulatory residents. The facility's approved for two (2) hospice waivers. The current census is five (5) residents. LPA Brown was accompanied by Staff #2 (S2) to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 76 degrees Fahrenheit. LPA Brown inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA Brown observed sufficient furniture and lighting throughout the facility. LPA Brown measured and observed the water temperature in a resident shared bathroom to be at 143 degree Fahrenheit. Deficiency will be issued. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Three (3) fire extinguishers were also observed at the facility. Posters such as personal rights, the CCLD complaint poster, Ombudsman poster labor laws, and the disaster plan were posted in a common area. ***Continuation in LIC809C ***
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: COMFORT HOME 2
FACILITY NUMBER: 366426081
VISIT DATE: 02/28/2024
NARRATIVE
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Cleaning supplies and sharps were kept inaccessible to residents in care. However, LPA Brown observed Staff #2 (S2) two (2) bottles of medication in the kitchen drawer, not locked and accessible to residents in care. Also, during the tour of the facility, LPA Brown observed plant fertilizer at the backyard, not locked and accessible to residents in care. Deficiency will be issued. Moreover, LPA Brown observed all residents medication for the day were pre-poured in a small container up to bedtime. Deficiency will be issued. There was a designated storage space for resident/staff files. There is a Medicine cabinet with the resident’s medications locked. LPA Brown observed the complete first aid kit and first aid book at the facility. Also, during the tour of the facility, LPA Brown observed side fence gate locked with a padlock. Deficiency will be issued. To add to that, LPA Brown observed screen door in disrepair. Deficiency will be issued. LPA Brown also observed Resident #1 (R1), Resident #3 (R3) and Resident #5 (R5) with half bed rails and no written order from their physician indicating the need for half bed rail for mobility. Deficiency will be issued.

Food Service: More than seven (7) days’ supply of Non-perishable foods and more than two (2) days’ supply of perishable food supply were observed and sufficient for the number of residents in care.

Care & Supervision: The facility has an Administrator present in the facility with appropriate and enough hours to appropriately manage the facility. The facility has sufficient number of staff to provide care and supervision to the residents in care.

Record Review: LPA Brown observed that the facility does not have updated liability insurance. Deficiency will be issued. Also, LPA Brown observed the facility not having the required Infection Control Plan. Deficiency will be issued. Moreover, LPA Brown observed no current fire drill or earthquake drill conducted at the facility. Deficiency will be issued. LPA Brown reviewed three (3) resident files for admission agreements, updated physician reports, pre-placement appraisals and needs and services plans. LPA Brown observed three (3) residents file reviewed do not have the required Pre-placement Appraisals and Needs and Services Plan. Deficiencies will be issued. LPA Brown reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test result. LPA Brown observed that Staff #5 (S5) does have criminal background clearance but the facility did not transfer S5 criminal background clearance to the facility. Deficiency will be issued. Also, during this visit, a civil penalty of $500.00 will be issued for not transferring S5 criminal record clearance to the facility.

***Continuation in LIC809C ***

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024
LIC809 (FAS) - (06/04)
Page: 2 of 10
Document Has Been Signed on 02/28/2024 03:50 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: COMFORT HOME 2
FACILITY NUMBER: 366426081

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not developing the required Infection Control Plan for the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/15/2024
Plan of Correction
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Licensee stated to develop the required Infection Control Plan and submit a copy to LPA Brown at Plan of Correction (POC) due date.
Type B
Section Cited
HSC
1569.605
HSC 1569.605 Other Provisions - On and afetr July 1, 2015, all residential residential care facilities for the elderly, except those facilities that are an integral part of continuing... shall maintain a liability insurance covering injury to residents and guests in the amount of...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not maintaining a liability insurance for the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2024
Plan of Correction
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Licensee stated to expedite processing of the renewal of their liability insurance and submit proof to LPA Brown at 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: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024
LIC809 (FAS) - (06/04)
Page: 3 of 10


Document Has Been Signed on 02/28/2024 03:50 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: COMFORT HOME 2
FACILITY NUMBER: 366426081

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
87705(f)(2) Care of Persons with Dementia (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes and toxic substances such as certain plans, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above by not locking the two (2) bottles of Staff #2 (S2) medications found in the kitchen cabinet and plant fertilizer found in the backyard, making it accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/29/2024
Plan of Correction
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Licensee stated to train all staff on CCR 87705(f)(2) and submit proof of all staff training log to LPA Brown at Plan of Correction (POC) due date.
Type A
Section Cited
CCR
87465(h)(5)
87465(h)(5) Incidental Medical and Dental Care (5) Each residents medication shall be stored in its originally received containier. NO medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by pre-pouring all residents medications for the day/transferring all residents medications for the day to a small container per resident which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/29/2024
Plan of Correction
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Licensee stated to train all staff on CCR 87465(h)(5) and submit proof of all staff training log to LPA Brown at 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: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/28/2024 03:50 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: COMFORT HOME 2
FACILITY NUMBER: 366426081

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(l)(2)
87705(l)(2) Care of Persons with Dementia (2) The Licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by locking the side fence gate with a padlock without approved fire clearance that includes approval of locked perimeter fence gate which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/29/2024
Plan of Correction
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Licensee immediately removed the padlock at the side gate of the facility during the visit.
Licensee stated to train all staff on CCR 87705(l)(2) and submit proof of all staff training log to LPA Brown at Plan of Correction (POC) due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024
LIC809 (FAS) - (06/04)
Page: 5 of 10


Document Has Been Signed on 02/28/2024 03:50 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: COMFORT HOME 2
FACILITY NUMBER: 366426081

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(c)
87303(c) Maintenance and OPeration (c) All window screens shall be clean and maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by having one (1) screen door in disrepair which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/15/2024
Plan of Correction
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Licensee stated to repair/replace the broken screen door and submit proof to LPA Brown at Plan of Correction (POC) due date.
Type B
Section Cited
CCR
87303(e)(2)
87303(e)(2) Faucets used by residents for personal care such as shaving and grooming... Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F and not more than 120 degree F.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not regulating the hot water temperature in residents' shared bathroom between 105 degree F to 120 degree F which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/08/2024
Plan of Correction
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Licensee stated to regulate the hot water temperature on residents shared bathroom between 105 degree F to 120 degree F and submit proof to LPA Brown at PLan of Correction (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: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024
LIC809 (FAS) - (06/04)
Page: 6 of 10


Document Has Been Signed on 02/28/2024 03:50 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: COMFORT HOME 2
FACILITY NUMBER: 366426081

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87355(e)(3)
87355(e)(3) Criminal Record Clearance - Request a transfer of a criminal record clearnace as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not transferring Staff #5 (S5) criminal background clearance to the facility before allowing S5 to work at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/15/2024
Plan of Correction
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Licensee stated to transfer S5 criminal record clearance to the facility and submit proof to LPA Brown at Plan of Correction (POC) due date.
Type B
Section Cited
CCR
87457(c)
87457(c) Pre-Admission Appraisal Prior to admission a determination of the prospective residents' suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not having the required Pre-Admission Appraisal for Resident #1 (R1), Resident #3 (R3) and Resident #5 (R5) which posesa potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/15/2024
Plan of Correction
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Licensee stated to submit Signed Statement of Understanding on CCR 87457(c) to LPA Brown at Plan of Correction (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: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024
LIC809 (FAS) - (06/04)
Page: 7 of 10


Document Has Been Signed on 02/28/2024 03:50 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: COMFORT HOME 2
FACILITY NUMBER: 366426081

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
15695(e)(2)
HSC 15695(e)(2) An appraisal of resident needs and services plan for each resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not completing the required needs and services plan for Resident # (R1), Resident #3 (R3) and Resident #5 (R5) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/08/2024
Plan of Correction
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Licensee stated to submit Signed Statement of Understanding on HSC15695(e)(2) and submit to LPA Brown at Plan of Correction (POC) due date.
Type B
Section Cited
HSC
1569.695(c)
HSC 1569.695(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered... 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
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not conducting the required drill at least quarterly for each shift which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/22/2024
Plan of Correction
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Licensee stated to conduct the required fire drill on all shift and submit proof to LPA Brown at Plan of Correction (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: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024
LIC809 (FAS) - (06/04)
Page: 8 of 10


Document Has Been Signed on 03/06/2024 12:02 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 03/06/2024 07:29 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: COMFORT HOME 2
FACILITY NUMBER: 366426081

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type B
Section Cited
CCR
87608(a)(5)(A)
87608(a)(5)(A) Postural Supports A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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Based on observation, interview and record review, the licensee did not comply with the section cited above by allowing Resident #1 (R1), Resident #3 (R3) and Resident #5 (R5) have half bed rails without their physician order indicating the need for half bed rail for mobility in their facility file which poses a potential health, safety or personal rights risk to persons in care. ***Deficiency will be deleted as it should be CCR 87608(a)(3)*** Please reference new LIC809D created***
POC Due Date: 03/15/2024
Plan of Correction
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Licensee stated to obtain doctor's written order indicating the need for half bed rail for R1, R3 and R5 and submit proof to LPA Brown at Plan of Correction (POC) due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024
LIC809 (FAS) - (06/04)
Page: 9 of 10


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: COMFORT HOME 2
FACILITY NUMBER: 366426081
VISIT DATE: 02/28/2024
NARRATIVE
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Medications/Medication Administration Record (MAR) were audited, and LPA Brown observed no issue.

Per LPA Brown's review, the facility were cited for the same violation on 11/17/2023 for CCR 87608(a)(5)(A) Postural Supports and CCR 87705(l)(2) Care of Persons with Dementia. During this visit, a civil penalty of $250.00 per regulation for repeating the same violation within 12 months will be issued.

Based on the observations made during today’s visit, deficiencies were issued per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809), LIC809D, LIC9102 and Appeal Rights were discussed and provided to Licensee Sushma Lal.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024
LIC809 (FAS) - (06/04)
Page: 10 of 10