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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366427230
Report Date: 07/12/2022
Date Signed: 07/12/2022 02:02:43 PM

Document Has Been Signed on 07/12/2022 02:02 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:BLOOMINGTON CARE CENTER INCFACILITY NUMBER:
366427230
ADMINISTRATOR:ALLISON A. LAYGOFACILITY TYPE:
735
ADDRESS:17552 MAYWOOD STTELEPHONE:
(909) 421-2006
CITY:BLOOMINGTONSTATE: CAZIP CODE:
92316
CAPACITY: 6CENSUS: 5DATE:
07/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Jennifer Nangaoang- CaregiverTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bernadette Allen made an unannounced visit to the facility to conduct an annual inspection focused on infection control. At 10:25 AM, LPA was greeted and granted entry by Caregiver Jennifer Nangaoang and she was informed of the purpose of my visit. At the time of visit there were 3 staff members and 4 residents present. The facility doesn't positive or suspected Covid-19 cases.

During today's visit, LPA toured the facility and made observations regarding the infection control measures that the facility has implemented. LPA observed Covid-19 postings posted throughout the facility. The facility has an adequate amount of hand hygiene supplies (soap, hand sanitizer). The staff were also observed wearing appropriate face coverings (surgical masks) at the time of visit.

The facility staff has a plan to manage Covid-19 symptoms, which includes staff monitoring residents regularly for any changes in condition, which includes daily temperature checks. The facility will contact the resident's physician should there be event of any COVID-19 related illnesses. The facility staff are responsible for cleaning and disinfecting the highly touched surfaces during their shift.

The outdoor and indoor hallways were also free of obstruction. The client rooms had the required furniture and sufficient lighting. The bathrooms can accommodate the needs for bathing and showers have non-slip flooring. The facility had a supply of additional linen and extra hygiene items for the clients. LPA measured the hot water temperature measured at 105.5 degrees F.

At 12:55 PM, LPA observed that there were no carbon monoxide detectors in the facility. The administrator Allison laygo was called to confirm if fire detectors were dual or not and it couldn't be confirmed.this poses an immediate health and safety risk to clients in care.

An exit interview was conducted, and a copy of this report was provided to Jennifer Nangaoang.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2022
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 07/12/2022 02:02 PM - It Cannot Be Edited


Created By: Bernadette Allen On 07/12/2022 at 01:27 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
, CA 92507

FACILITY NAME: BLOOMINGTON CARE CENTER INC
FACILITY NUMBER: 366427230

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1503.2


This requirement is not met as evidenced by:
Deficient Practice Statement
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ยง1503.2 Carbon monoxide detectors required; inspection Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12... This requirement is not met as evidenced by:Based on observation, licensee did not ensure that the facility is equipped with a carbon monoxide alarm, which poses an immediate health and safety risk to clients in care.
POC Due Date: 07/13/2022
Plan of Correction
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Licensee will purchase an operating carbon monoxide alarm and install it in a common area of the facility. Licensee will send proof by submitting pictures to the department by POC date 7/13/2022.
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:Karen Clemons
LICENSING EVALUATOR NAME:Bernadette Allen
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2022


LIC809 (FAS) - (06/04)
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