<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366427078
Report Date: 09/11/2024
Date Signed: 09/11/2024 12:45:39 PM

Document Has Been Signed on 09/11/2024 12:45 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:HOLLY LAND CARE HOMEFACILITY NUMBER:
366427078
ADMINISTRATOR/
DIRECTOR:		OLIVER DINEROSFACILITY TYPE:
735
ADDRESS:2044 HOLLY AVENUETELEPHONE:
(909) 972-8497
CITY:ONTARIOSTATE: CAZIP CODE:
91762
CAPACITY: 6CENSUS: 4DATE:
09/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Clark Pilapil TIME VISIT/
INSPECTION COMPLETED:
01:00 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 09/11/2024 at 09:00 AM, Licensing Program Analysts (LPAs) Melody Brown and Eldin Serrano conducted an unannounced visit to the facility to conduct the required comprehensive annual inspection to the facility. LPAs Brown and Serrano were greeted by a staff and gained access at the home. Administrator Oliver Dineros was contacted and arrived during the visit. LPAs Brown and Serrano explained the purpose of the visit to Administrator Oliver Dineros.

The facility has four (4) bedrooms, two (2) bathrooms, kitchen, dining room, living room, attached garage, and backyard. The facility is vendorized by Inland Regional Center (IRC). The facility are licensed for 6 of which can be non-ambulatory. LPAs Brown and Serrano completed a walkthrough of the facility, review of records, Personal and Incidental (P&I) and medications audit.



Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD), LPAs Brown and Serrano observed two (2) clients but clients left for the scheduled activity for the day during the visit. There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 74 degrees Fahrenheit. LPAs Brown and Serrano inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, chairs, and sufficient lighting. LPAs Brown and Serrano inspected client bathrooms; bathrooms were clean, and appliances were found functional. Water temperatures tested at 110 degrees Fahrenheit. The facility is equipped with operational combined smoke detectors and carbon monoxide detectors, charged fire extinguishers, and first aid kit with first aid book. In addition, during the tour of the facility LPAs observed part of the living room was converted to a staff room. Per records review and staff interview no permit was obtained prior to the alteration made at the facility and CCLD was also not informed of the alteration made. Deficiency will be issued.

*** Continuation in LIC809C ***
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE: DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2024
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 10
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: HOLLY LAND CARE HOME
FACILITY NUMBER: 366427078
VISIT DATE: 09/11/2024
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
26
27
28
29
30
31
32
Posters such as the personal rights, CCLD complaint poster, and emergency disaster plan were posted in a common area. Client medications were kept in secure cabinets inaccessible to clients. LPAs Brown and Serrano observed that there were no night lights at the hallway leading to clients' shared bathrooms. Deficiency will be issued. The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility.

Yards/Outside: One shaded patio, one (1) side gate with self-latching handle on the right side of the house that leads into the backyard, attached two (2) car garage observed. All outdoor pathways were free of obstructions.

Food Service: LPAs Brown and Serrano observed two (2) day(s) supply of perishable food and seven (7) day(s) supply of non-perishables food and snacks. 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: LPAs Brown and Serrano reviewed two (2) client files for admission agreements, medical assessments/physician reports, and Individual Program Plan (IPP). LPAs Brown and Serrano observed files reviewed were complete. However, LPAs Brown and Serrano observed client one (C1) with restricted health condition but no restricted health care plan maintained at the facility. Deficiency will be issued. In addition, per records review and staffs interview LPAs noted that staff are performing client 1(C1) glucose meter testing and per documents review no training was provided to the staff by a licensed professional. Deficiency will be issued. LPAs Brown and Serrano also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test result. LPAs Brown and Serrano observed Staff #4 (S4) does not have Health Screening Report in S4 file. Deficiency will be issued.

LPAs Brown and Serrano audited two (2) clients’ medications and no issues were observed. LPAs Brown and Serrano audited two (2) client's Personal and Incidental (P&I) and no issues observed.

Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809D,LIC 9102 and Appeal Rights were discussed, and copies were provided to staff Clark Pilapil.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024
LIC809 (FAS) - (06/04)
Page: 2 of 10
Document Has Been Signed on 09/11/2024 12:45 PM - It Cannot Be Edited


Created By: Eldin Serrano On 09/11/2024 at 11:35 AM
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: HOLLY LAND CARE HOME
FACILITY NUMBER: 366427078

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80066(a)(10)
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: (10) A health screening as specified in Section 80065(g).

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 ensuring that staff 4 (S4) complete the the required health screening/medical assessment prior to employment which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/12/2024
Plan of Correction
1
2
3
4
Licensee stated to submit S4 medical appointment to complete the required health screening reprot and submit proof to LPA Serrano on plan of correction (POC) due date.
Type A
Section Cited
CCR
80075(b)(2)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (2) Facility staff, except those authorized by law, shall not administer injections but staff designated by the licensee shall be authorized to assist clients with self-administration of injections as needed.

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 ensuring that staffs were provided the required training to perform blood glucose test by a licensed professional as evidence of per records review and interview with staffs, no trainings were provided to them by a license professional which poses a immediate health, safety, and personal rights risk to clients in care.
POC Due Date: 09/12/2024
Plan of Correction
1
2
3
4
Licensee stated to have a licensed professional train all the staff on how to perform blood glucose test for client 1 (C1) and submit proof to LPA Serrano 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.
SUPERVISOR'S NAME:Karen Clemons
LICENSING EVALUATOR NAME:Eldin Serrano
LICENSING EVALUATOR SIGNATURE:
DATE: 09/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2024


LIC809 (FAS) - (06/04)
Page: 3 of 10
Document Has Been Signed on 09/11/2024 12:45 PM - It Cannot Be Edited


Created By: Eldin Serrano On 09/11/2024 at 11:36 AM
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: HOLLY LAND CARE HOME
FACILITY NUMBER: 366427078

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(5)(B)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions.

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 ensuring that client 3 (C3) one (1) medication was given according to C3 physicians direction as evidenced of staff did not update C3 medication administration record (MAR) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/12/2024
Plan of Correction
1
2
3
4
Licensee stated to train all staff on CCR 80075(b)(5)(B) and submit proof to LPA Serrano on plan of correction (POC) due date.
Type A
Section Cited
CCR
80092.2(a)
Restricted Health Condition Care Plan
(a) If the licensee of an ARF chooses to care for a client with a restricted health condition, as specified in Section 80092, the licensee shall develop and maintain, as part of the Needs and Services Plan, a written Restricted Health Condition Care Plan. The plan must include all of the following:

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 ensuring that client 1 (C1) has an approved restricted health care plan prior to admission and must be mantained at C1 file which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/12/2024
Plan of Correction
1
2
3
4
Licensee stated to submit the required restricted health care plan for C1 to LPA Serrano 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.
SUPERVISOR'S NAME:Karen Clemons
LICENSING EVALUATOR NAME:Eldin Serrano
LICENSING EVALUATOR SIGNATURE:
DATE: 09/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2024


LIC809 (FAS) - (06/04)
Page: 4 of 10
Document Has Been Signed on 09/11/2024 12:45 PM - It Cannot Be Edited


Created By: Eldin Serrano On 09/11/2024 at 11:43 AM
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: HOLLY LAND CARE HOME
FACILITY NUMBER: 366427078

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80086(c)
80086 Alterations to Existing Building or New Facilities (c) Prior to construction or alterations, state or local law requires that all facilites secure a building permit.

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 securing a building permit for the alteration made at the facility as evidence of part of the living room converted to a staff room which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/14/2024
Plan of Correction
1
2
3
4
Licensee stated to secure a building permit for or the alteration made at the facility as evidence of part of the living room converted to a staff room and submit to LPA Serrano 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.
SUPERVISOR'S NAME:Karen Clemons
LICENSING EVALUATOR NAME:Eldin Serrano
LICENSING EVALUATOR SIGNATURE:
DATE: 09/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2024


LIC809 (FAS) - (06/04)
Page: 10 of 10