366427230-9-28-2023-56-AS-MMAE-CW4UGX-20230928153504

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366427230
Report Date: 09/28/2023
Date Signed: 09/28/2023 03:35:35 PM

Document Has Been Signed on 09/28/2023 03:35 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:	BLOOMINGTON CARE CENTER INC		FACILITY NUMBER:	366427230
ADMINISTRATOR:	JUDELSON ENRIQUEZ		FACILITY TYPE:	735
ADDRESS:	17552 MAYWOOD ST		TELEPHONE:	(909) 421-2006
CITY:	BLOOMINGTON	STATE: CA	ZIP CODE:	92316
CAPACITY: 6		CENSUS: 4	DATE:	09/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Cielita Ravelo, Administrator		TIME COMPLETED:	03:20 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

Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced required 1-year visit to the facility. LPA met with Cielita Ravelo, Administrator and discussed the purpose of the visit.

The facility is an Adult Residential Facility (ARF), license capacity of (6) with a current census of (4). LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:

LPA inspected the facility inside and out. Indoor and outdoor passageways are kept free of obstruction. Facility has no bodies of water and no firearms. Facility backyard is fenced with self-latching gates. The facility has sufficient lighting and is maintained at a comfortable temperature.

LPA inspected the kitchen. Hot water temperature tested at 105 degrees F. Facility has sufficient non-perishable and perishable food for number of clients in care. Facility food is stored in a safe and healthful manner. Facility has sufficient cups, plates, and utensils for client use. Sharps, disinfectants, and chemicals are kept safe and locked.

LPA inspected client bedrooms. Bedroom furniture is in good condition. Bedrooms have sufficient linen and lighting.

LPA inspected client bathrooms. Bathrooms are operating in safe and sanitary conditions. Hot water temperatures tested between 105 and 110 degrees F.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

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 3

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: BLOOMINGTON CARE CENTER INC	FACILITY NUMBER: 366427230
	VISIT DATE: 09/28/2023

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

The facility is equipped with operating carbon monoxide alarms. Emergency drill was conducted on 5/25/23. Facility has posted in a common area the facility sketch, personal rights, disaster plan and emergency numbers. Facility has complete first aid kit and emergency supplies, including bottled water. Facility has sufficient supply of linen, towels, and hygiene products for clients in care.

LPA inspected client medications. Medications are labeled and administered as prescribed. Medications are kept locked and inaccessible to clients in care.

LPA reviewed client files for admission agreements, Individual Program Plan (IPPs), physician reports and record of client safeguarded resources. Client 1 (C1) last IPP was conducted in August 2021, Administrator stated that she will provide the Licensing agency copy of IPP report for 2022 and has made an appointment for IPP visit with Inland Regional Center Coordinator for October 2023.

LPA reviewed staff files for criminal record clearances, first aid certifications, training, and health screenings. Staff 1 (S1) had an incomplete health screening.

An exit interview was conducted, where this report and deficiencies were discussed and a copy with appeal rights was provided to the administrator at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 09/28/2023 03:35 PM - It Cannot Be Edited

Created By: Magda Malcore On 09/28/2023 at 03:17 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: BLOOMINGTON CARE CENTER INC	FACILITY NUMBER: 366427230
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80066(a)(11)

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: (11) Tuberculosis test documents as specified in Section 80065(g). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA record review, the licensee did not comply with the section cited above by staff 1 (S1) health screening was incomplete which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/25/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator shall submit to the Licensing Agency health screening results by POC date.

Type B

Section Cited

CCR

85068.3(a)

Modifications to Needs and Services Plan

(a) The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental and/or social functioning. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA record review, the licensee did not comply with the section cited above by Client 1 (C1) last IPP on file was August 2021 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/25/2023
	Plan of Correction
1 2 3 4	Licensee/administrator shall provide to the licensing agency proof of current IPP by POC 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: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3