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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426795
Report Date: 10/11/2024
Date Signed: 10/11/2024 03:31:52 PM

Document Has Been Signed on 10/11/2024 03:31 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/
DIRECTOR:		DARLENE M. MORENOFACILITY TYPE:
735
ADDRESS:11649 IVY AVENUETELEPHONE:
(760) 669-2024
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY: 4CENSUS: 4DATE:
10/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:10 PM
MET WITH:Darlene Moreno TIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA was granted entry into the facility and discussed the purpose of the visit with Administrator, Darlene Moreno. The facility is an Adult Residential facility with a license capacity of (4) and a current census (4). During today's visit (1) client and (2) staff were present at the facility. LPA conducted an overall inspection, which included, but was not limited to, the following:

Operation/Physical Plant: The facility is operating within the capacity approved by Community Care Licensing Division. Indoor and outdoor passageways were kept free of obstruction. The facility has no swimming pools or similar bodies of water. The facility's outdoor activity space is shaded and enclosed with a self-latching gate. The facility is equipped with smoke/carbon monoxide alarms, fully charged fire extinguisher, laundry equipment and telephone service. Client bedrooms inspected were equipped with beds, chairs, dressers and operating lights. Client bathroom equipment were fully operational. The hot water in client bathroom tested at 105.4 and 111 degrees F. Sharps, disinfectants and cleaning supplies were kept locked. The facility has infection control plan and client registry for review. The facility has posted: facility license, emergency numbers, staff schedule, client activities and Community Care Licensing complaint poster. LPA requested documentation of a complete emergency and disaster plan for review; the Administrator stated they did not have a current plan for review.

Food Service: The facility’s dining area and kitchen was maintained clean. The facility has sufficient non-perishable and perishable food for number of clients in care.

Health Related Services: The facility maintains records of client medications and medications are centrally stored in a locked room. The facility maintains emergency supplies, a first aid kit and manual.

Personnel/Client Records: Staff records were reviewed for employment history, health screenings, criminal record clearances, crisis prevention training, first aid/CPR certifications, and Administrator's certification. Client records were reviewed for IRC placement/admission agreements, medical assessments, needs and service plans, and personal/incidentals (P&I) .

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2024
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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Document Has Been Signed on 10/11/2024 03:31 PM - It Cannot Be Edited


Created By: Magda Malcore On 10/11/2024 at 02:13 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: 10/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 LPA observations, the licensee did not comply with the section cited above by client #1 did not have operating lighting in their bedroom; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/25/2024
Plan of Correction
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The Administrator has agreed to submit proof of operating lighting in client #1's bedroom to the licensing agency by POC due date.
Type B
Section Cited
HSC
1507(c)(1)(B)
General Provisions
(1) For regional center clients the following shall apply: (B) The client's individualized health care plan shall be reassessed at least every 12 months or more frequently as determined by the client's physician or nurse practitioner during the time the client receives incidental medical services in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's record review, the licensee did not comply with the section cited above in by not maintaining a current medical assessment for all four clients; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/25/2024
Plan of Correction
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The Administrator has agreed to submit proof of current medical assessment to the licensing agency 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:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/11/2024 03:31 PM - It Cannot Be Edited


Created By: Magda Malcore On 10/11/2024 at 02:13 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: 10/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80068.3(a)
Modifications to Needs and Services Plan
(a) The licensee shall ensure that each client's written Needs and Services Plan is updated as often as necessary to assure its accuracy, but at least annually. These modifications shall be maintained in the client's file.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observations, the licensee did not comply with the section cited above by not maintaining current and completed IPP's for Client #1, #2, #3; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/25/2024
Plan of Correction
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The Administrator has agreed to submit documentation of current IPP's.
Section Cited
Client Records
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:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/11/2024 03:31 PM - It Cannot Be Edited


Created By: Magda Malcore On 10/11/2024 at 02:13 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: 10/11/2024

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 LPA observations, the licensee did not comply with the section cited above by not having access to Client #1, #2, and #3 P&I funds for licensing to audit; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/25/2024
Plan of Correction
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The Licensee/Administrator shall submit a statement of understanding of the regulation cited.
Type B
Section Cited
CCR
80023(a)
Client Records
Each licensee shall have and maintain on file a current, written disaster and mass casualty plan of action.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review, the licensee did not comply with the section cited above by not maintaining a complete and current emergency and disaster plan on file for review; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/25/2024
Plan of Correction
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The Administrator stated that they will complete and submit the plan to the licensing agency 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:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2024


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: 10/11/2024
NARRATIVE
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 LPA requested to review all four client's P&I funds for auditing. The Administrator stated that they only had client #4 (C4) funds available as they currently did not have a key to access other clients P&I funds. LPA review of clients reveals Client #1(C1), #2(C2), #3(C3) did not have a current and complete IPP on file for review. C1, C2, and C3 did not have a current medical assessment which identifies current client's needs, physical status and medical status. The Administrator stated that the clients have been seen by a physicians and is waiting for the reports from the physician.

During today's visit, technical advisories and citations were issued in accordance with Title 22, chapter 6, of the California Code of Regulations.



An exit interview was conducted where this report and correction plans were discussed. Copies of the licensing reports were provided with Appeal rights to the staff Isaac Cardenas, DSP at the conclusion of the visit.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2024
LIC809 (FAS) - (06/04)
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