366426281-12-26-2024-56-AS-ESEO-DCBTQC-20241226135542

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366426281
Report Date: 12/26/2024
Date Signed: 12/26/2024 01:56:01 PM

Document Has Been Signed on 12/26/2024 01:56 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	TERRACE GARDENS		FACILITY NUMBER:	366426281
ADMINISTRATOR/ DIRECTOR:	MAWIKERE, DEKKI		FACILITY TYPE:	740
ADDRESS:	22626 FLAMINGO ST.		TELEPHONE:	(909) 824-8126
CITY:	GRAND TERRACE	STATE: CA	ZIP CODE:	92313
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	12/26/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:10 AM
MET WITH:	Dekki Mawikere, Administrator		TIME VISIT/ INSPECTION COMPLETED:	02:10 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	On 12/26/2024 at 09:10 AM, Licensing Program Analyst (LPA) Eldin Serrano made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection LPA Serrano met with caregiver Margaretha Jacobus and was granted entry to the facility. Caregiver called the administrator Dekki Mawikere and the administrator arrived after 3 hours. At the time of the visit there was three (3) staff present, and six (6) residents present. The facility is a four (4) bedrooms, two (2) bathroom home with a kitchen/dining area, living room/activity room. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) non-ambulatory and three (3) hospice care and the current census is six (6) residents. LPA Serrano was accompanied by Staff 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 72 degrees Fahrenheit. LPA Serrano 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 observed sufficient furniture and lighting throughout the facility. LPA Serrano measured and observed the water temperatures in the bathroom to be at 116 degrees Fahrenheit. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Fire extinguishers were also observed at the facility. Posters such as personal rights, the CCLD complaint poster, labor laws, and the disaster plan were posted in a common area. LPA observed that the facility does not have the Infection Control Plan available for review at the time of visit. Deficiency will be issued. *Continuation in LIC809C *

Karen Clemons	TELEPHONE: (951) 836-2784
Eldin Serrano	TELEPHONE: 951-248-0351
	DATE: 12/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2024

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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: TERRACE GARDENS	FACILITY NUMBER: 366426281
	VISIT DATE: 12/26/2024

NARRATIVE

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Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. The resident’s medication is locked. LPA Serrano observed complete first aid kit and first aid book at the facility.

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 sufficient number of staff to provide care and supervision to the residents in care.

Record Review: LPA Serrano reviewed five (5) resident files for admission agreements, updated physician reports, pre-placement appraisals and needs and services plans. LPA Serrano observed resident files reviewed were complete. LPA Serrano reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA observed that Staff #1 (S1) has an expired CPR/First Aid certification and Staff #2 (S2) does not have a CPR/First Aid certification on file. Deficiency will be issued. LPA observed that resident #2 (R2) and resident #5 (R5) does not have the physician's report on file. Deficiency will be issued. LPA observed that resident #4 (R4) does not have the admission agreement on file. Deficiency will be issued.

Based on the observations made during today’s visit, Five (5) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report LIC809, LIC809D forms, and Appeal Rights were discussed and provided to Administrator Dekki Mawikere.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Eldin Serrano	TELEPHONE: 951-248-0351
LICENSING EVALUATOR SIGNATURE:	DATE: 12/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/26/2024 01:56 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: TERRACE GARDENS	FACILITY NUMBER: 366426281
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Resident Records

(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by not ensuring that resident #4 (R4) have the admission agreement on file which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/27/2024
	Plan of Correction
1 2 3 4	Licensee to submit a copy of the admission agreement by the plan of correction (POC) due date.

Section Cited

Medical Assessment

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by not ensuring that resident #2 (R2) and resident #5 (R5) has the required physician's report on file. Licensee did not ensure that the residents has the required tuberculosis (TB) test and TB test result, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/27/2024
	Plan of Correction
1 2 3 4	Licensee to submit proof of date of appointment with a physician to have the physician's report by the 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.

Karen Clemons	TELEPHONE: (951) 836-2784
Eldin Serrano	TELEPHONE: 951-248-0351
	DATE: 12/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/26/2024 01:56 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: TERRACE GARDENS	FACILITY NUMBER: 366426281
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Other Provisions

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by not ensuring that Staff #1 (S1) has an updated CPR/First Aid certification and Staff #2 (S2) have a CPR/First Aid certification on file, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/24/2025
	Plan of Correction
1 2 3 4	Licensee to submit proof of CPR/First Aid certificate on 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.

Karen Clemons	TELEPHONE: (951) 836-2784
Eldin Serrano	TELEPHONE: 951-248-0351
	DATE: 12/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2024

LIC809 (FAS) - (06/04)

Page: 5 of 5

Document Has Been Signed on 12/26/2024 01:56 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: TERRACE GARDENS	FACILITY NUMBER: 366426281
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Plan of Operation

(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: (12) The Infection Control Plan pursuant to Section 87470. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, record review, the licensee did not comply with the section cited above by not ensuring that the facility have the Infection Control Plan available for review at the time of visit, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/02/2025
	Plan of Correction
1 2 3 4	Licensee to submit a copy of Infection Control Plan for review on the plan of correction (POC) due date.

Section Cited

Other Provisions

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by not ensuring that the facility have an updated liability insurance.which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/24/2025
	Plan of Correction
1 2 3 4	Licensee to submit proof of liability insurance on 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.

Karen Clemons	TELEPHONE: (951) 836-2784
Eldin Serrano	TELEPHONE: 951-248-0351
	DATE: 12/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2024

LIC809 (FAS) - (06/04)

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