366426224-7-11-2024-56-AS-BALN-D73T4J-20240711142400

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366426224
Report Date: 07/11/2024
Date Signed: 07/11/2024 02:24:13 PM

Document Has Been Signed on 07/11/2024 02:24 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:	DOVE TREE MANOR		FACILITY NUMBER:	366426224
ADMINISTRATOR:	SOSNOVSKY, EVA FE		FACILITY TYPE:	740
ADDRESS:	3991 DOVE TREE AVE.		TELEPHONE:	(909) 441-7891
CITY:	RIALTO	STATE: CA	ZIP CODE:	92377
CAPACITY:	6	CENSUS: 5	DATE:	07/11/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Bonna Ferrer-Caregiver		TIME COMPLETED:	02:40 PM

NARRATIVE

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Licensing Program Analyst (LPA) Bernadette Allen made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Bonna Ferrer-Caregiver who granted entry into the facility.

Licensed capacity is four (6) current census five(5). LPA was accompanied by Bonna Ferrer 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 (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately.

LPA observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors, carbon monoxide alarms and extinguishers. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area.

Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. All sharps are locked in kitchen drawer. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care. The hot water temperature tested within regulation at 124 degrees F.

Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a variety of food available for clients. Dishes, cups, and utensils were also stored properly.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette Allen	TELEPHONE: 951-897-2618
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)

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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: DOVE TREE MANOR	FACILITY NUMBER: 366426224
	VISIT DATE: 07/11/2024

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Record Review: LPA reviewed two (2) client files for admission agreements, updated physician reports, and needs and services plans. LPA reviewed two (2) client medications/MAR which were not signed by facility staff for 3-5 days this poses immediate danger to those in care.

LPA also reviewed one (2) staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings. There was a designated area for client/staff files.

Based on the observations made during today’s visit, there was a deficiency cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809, LIC809-C and LIC809-D) was discussed and provided to Bonna Ferrer at the conclusion of the visit.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette Allen	TELEPHONE: 951-897-2618
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

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 07/11/2024 02:24 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: DOVE TREE MANOR	FACILITY NUMBER: 366426224
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(a)(6)

6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained at the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not having Resident # 1 (R1) and Resident #2 (R2) Medication Administration Record (MAR) documented on record for days that R1 and R2 medications were dispensed per physicians order which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/12/2024
	Plan of Correction
1 2 3 4	The Licensee has agreed to train all staff on CCR 87465(a)(6) with statement of understanding signed by all staff by the POC date of 7/12/2024.

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: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette Allen	TELEPHONE: 951-897-2618
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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