366427615-8-16-2023-56-AS-MMAE-CURRUQ-20230816132020

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366427615
Report Date: 08/16/2023
Date Signed: 08/16/2023 01:20:29 PM

Document Has Been Signed on 08/16/2023 01:20 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:	GARDEN VILLE HOME CARE		FACILITY NUMBER:	366427615
ADMINISTRATOR:	ADA REYES		FACILITY TYPE:	740
ADDRESS:	6206 WALNUT AVE		TELEPHONE:	(909) 548-0487
CITY:	CHINO	STATE: CA	ZIP CODE:	91710
CAPACITY:	6	CENSUS: 5	DATE:	08/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Dulce Redford, Licensee		TIME COMPLETED:	01:15 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 made an unannounced visit to the facility to conduct a required 1 year inspection. LPA met with Dulce Redford, Licensee and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE). License capacity of (6) clients and a current census of (5). Hospice waiver for (2). 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 free of obstruction. The facility has sufficient lighting and is maintained at a comfortable temperature. Fireplace is adequately screened. Facility has no outdoor bodies of water. Facility has sufficient indoor and outdoor space for clients. The fenced facility has self-latching gates and covered outdoor patio. LPA inspected the kitchen. The refrigerator and freezer are operating in a safe and healthful manner. Hot water temperature is maintained at 109 degrees F. Facility has sufficient non-perishable and perishable food supply for the number of clients in care. Facility has sufficient cups, plates, and utensils for client use. LPA inspected client bedrooms. Bedrooms are equipped with beds, linen, nightstands, chairs, storage space and sufficient lighting.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023

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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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: GARDEN VILLE HOME CARE	FACILITY NUMBER: 366427615
	VISIT DATE: 08/16/2023

NARRATIVE

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LPA inspected client bathrooms. Bathroom equipment is operating in a safe and sanitary condition. The hot water bathroom temperatures tested between 105 and 108 degrees F.

LPA observed the facility is equipped with operating smoke alarms and fully charged fire extinguishers. Facility has operating telephone service on the premises. Posters such as ombudsman contacts, emergency phone numbers, and evacuation plan are posted in a common area. Sharps, disinfectants, cleaning solutions, and toxins are kept locked and inaccessible to clients in care. Facility has sufficient supply of personal hygiene products, linen, towels, and emergency supplies for clients in care.

Client medications are kept in a safe and locked cabinet inaccessible to clients in care. All medications are labeled and administered as prescribed.

LPA reviewed (3) staff files for first aid certifications, fingerprint clearances/exemptions, health screenings, training, and personnel records. (3) of (3) staff did not have the appropriate training and health screening. (1) out of (3) staff did not have the proper criminal background clearance. LPA observed Administrator certification is expired. Deficiencies cited.

All client records reviewed had admissions agreements, physician's reports, personal rights: Residential Care for the Elderly, and safeguarded cash resource records.

An exit interview was conducted, where reports (LIC809 & LIC809D) were discussed and a copy the reports with appeal rights was provided to the Licensee at the conclusion of the visit.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/16/2023 01:20 PM - It Cannot Be Edited

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: GARDEN VILLE HOME CARE	FACILITY NUMBER: 366427615
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA review and regional office contact, the licensee did not comply with the section cited above by (1) staff did not have the proper criminal background clearance which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/17/2023
	Plan of Correction
1 2 3 4	Licensee immediately had uncleared staff leave the facility. Administrator/Licensee shall submit a statement of understanding of the cited regulation and state that the uncleared staff will not return to the facility until background clearance is verified.

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	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/16/2023 01:20 PM - It Cannot Be Edited

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: GARDEN VILLE HOME CARE	FACILITY NUMBER: 366427615
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(d)

Personnel Records

(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA file review and interview, the licensee did not comply with the section cited above by Administrator certification was expired which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/15/2023
	Plan of Correction
1 2 3 4	Administrator/Licensee to provide proof of recertification to the licensing agency by POC date

Type B

Section Cited

CCR

87411(d)

Personnel Requirements - General

(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA file review, the licensee did not comply with the section cited above by (3) of (3) staff did not have the appropriate training which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/31/2023
	Plan of Correction
1 2 3 4	Administrator/Licensee to submit proof of training to the licensing agency 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	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023

LIC809 (FAS) - (06/04)

Page: 12 of 13

Document Has Been Signed on 08/16/2023 01:20 PM - It Cannot Be Edited

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: GARDEN VILLE HOME CARE	FACILITY NUMBER: 366427615
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(c)(1)

Personnel Requirements - General

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA file review, the licensee did not comply with the section cited above by (3) of (3) staff did not have the appropriate training, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/31/2023
	Plan of Correction
1 2 3 4	Administrator/Licensee to submit proof of training to the licensing agency by POC date

Type B

Section Cited

CCR

87411(f)

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA file review, the licensee did not comply with the section cited above by (3) out of (3) staff did not have the appropriate health screening, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/31/2023
	Plan of Correction
1 2 3 4	Administrator/Licensee to submit proof of health screening to the licensing agency 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	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023

LIC809 (FAS) - (06/04)

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