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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426795
Report Date: 10/02/2023
Date Signed: 10/02/2023 05:47:25 PM

Document Has Been Signed on 10/02/2023 05:47 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:HANA HOMEFACILITY NUMBER:
366426795
ADMINISTRATOR:DARLENE M. MORENOFACILITY TYPE:
735
ADDRESS:11649 IVY AVENUETELEPHONE:
(760) 669-2024
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY: 4CENSUS: 4DATE:
10/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:08 PM
MET WITH:Silvia Rodriguez-StaffTIME COMPLETED:
05:52 PM
NARRATIVE
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On 10/02/23, Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with Staff, Silvia Rodriguez introduced self and stated purpose of the visit.

The facility has 4 bedrooms, 3 bathrooms, kitchen, dining, living room, family room, office, laundry room, attached garage, and backyard. The facility is vendorized by Inland Regional Center. LPA completed a walk through of the facility and review of records.

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 of 74 degrees fahrenheit. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA observed chairs missing in bedroom #2 and #4. Deficiency issued. LPA inspected client bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 119.1 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarm, charged fire extinguisher, and first aid kit. Posters such as; the personal rights, CCL complaint poster and emergency disaster plan were posted in the office. LPA observed that the Emergency Disaster Plan is outdated and last reviewed on 09/20/21. Deficiency issued. LPA observed that cleaning supplies, toxins, and sharps were kept locked and inaccessible to clients. LPA observed medication packs with some pills left inside made accessible to clients. Deficiency issued. The facility had emergency kits and emergency water. There are no firearms, ammunition or bodies of water. LPA observed a broken counter in front of the sink and broken drawers in the kitchen. Deficiency issued.

Yards/Outside: One shaded patio, a side gate with self-latching handle on the right side of the house that leads into the backyard. All outdoor pathways were free of obstructions.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 10/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/02/2023
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 7
Document Has Been Signed on 10/02/2023 05:47 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 10/02/2023 at 04:30 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: HANA HOME
FACILITY NUMBER: 366426795

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the administrator did not comply with the section cited above in making medication inaccessible which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/02/2023
Plan of Correction
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Staff locked medication packs right away. Administrator stated that she will hold a staff training reviewing regulation 80087(g). Administator will submit proof of training to LPA via email by 10/09/23.
Type A
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the administrator did not comply with the section cited above in having one week staple of nonperishable and two days staple of perishable which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/03/2023
Plan of Correction
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Administrator stated that she will purchase one week staple of nonperishable and two days staple of perishable. Administrator will submit proof of receipts and pictures of food to LPA via email by 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:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 10/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2023


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 10/02/2023 05:47 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 10/02/2023 at 04:30 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: HANA HOME
FACILITY NUMBER: 366426795

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the Administrator did not comply with the section cited above in having the counter and drawer in the kitchen in good repair which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/16/2023
Plan of Correction
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Administrator stated that she will have the counter and drawer in the kitchen repaired. Administrator stated that she will submit a picture as proof to LPA via email by POC due date.
Type B
Section Cited
CCR
85088(c)(2)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (2) Bedroom furniture including, in addition to (c)(1) above, for each client, a chair, a night stand, and a lamp or lights necessary for reading.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the administrator did not comply with the section cited above in having a chair in bedroom #2 and #4 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/16/2023
Plan of Correction
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Administrator stated that she will furnish bedroom #2 and #4 with a chair and submit proof to LPA via email by 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:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 10/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2023


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 10/02/2023 05:47 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 10/02/2023 at 04:30 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: HANA HOME
FACILITY NUMBER: 366426795

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the administrator did not comply with the section cited above in ensuring personnel records were readily available to LPA during visit which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/16/2023
Plan of Correction
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Administrator stated that she will submit proof of personnel records to LPA. Administrator stated that she will submit a statement of understanding on regulation 80066(a) to LPA via email by POC due date.
Type B
Section Cited
CCR
80069(b)
Client Medical Assessments
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the administrator did not comply with the section cited above in having on file a physician's report for client which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/16/2023
Plan of Correction
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Administrator stated that she will obtain and submit the physician's report that is missing for client. Administrator stated that she will submit proof to LPA via email by 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:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 10/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2023


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 10/02/2023 05:47 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 10/02/2023 at 04:30 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: HANA HOME
FACILITY NUMBER: 366426795

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(d)
Client Records
(d) All client records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the administrator did not comply with the section cited above in having clients records available to LPA for inspection which poses potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/16/2023
Plan of Correction
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Administrator stated that she will submit a statement of understanding on regulation 80070(d) to LPA via email by POC due date. Administrator stated that she will have all clients records available to LPA for inspection, audit and copy during any visit made.
Type B
Section Cited
HSC
1565(d)
Other Provisions
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee, administrator, or regulated individual shall sign and date the documentation to indicate that the plan has been reviewed and updated as necessary.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the administrator did not comply with the section cited above in reviewing/updating annually the emergency disaster plan which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/16/2023
Plan of Correction
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Administrator stated that she will review and update the emergency disaster plan and submit proof to LPA via email by 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:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 10/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2023


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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: HANA HOME
FACILITY NUMBER: 366426795
VISIT DATE: 10/02/2023
NARRATIVE
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Food Service: LPA observed that the facility did not have a 2 days of perishables and 7 days non-perishables food. Deficiency issued. Dishes, cups, and utensils were stored properly.

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

Record Review: LPA reviewed clients file for admission agreements, updated physician reports, and needs and services plans. LPA observed a missing physician's report for client. Deficiency issued. LPA was not able to review staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings due to staff did not have access and administrator was not present to have files readily available to LPA. Deficiency issued. LPA was unable to audit P& I due to client records not being readily available to LPA. Deficiency issued. LPA observed that the facility did not have an infection control plan. Deficiency issued.

Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D and appeal rights were discussed and copies were provided to Staff, Silvia Rodriguez.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2023
LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 10/02/2023 05:47 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 10/02/2023 at 05:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: HANA HOME
FACILITY NUMBER: 366426795

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(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 85022. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the administrator did not comply with the section cited above in including an Infection Control Plan in the facility file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/16/2023
Plan of Correction
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Administrator stated that she will submit a completed Infection Control Plan to LPA via email by 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:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 10/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2023


LIC809 (FAS) - (06/04)
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