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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530023
Report Date: 08/09/2024
Date Signed: 08/12/2024 11:20:08 AM

Document Has Been Signed on 08/12/2024 11:20 AM - 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:COMPASSION HOME 1FACILITY NUMBER:
335530023
ADMINISTRATOR/
DIRECTOR:		WRIGHT-ILORI, ROSEFACILITY TYPE:
740
ADDRESS:825 CHALLENGE AVENUETELEPHONE:
(614) 394-5674
CITY:BEAUMONTSTATE: CAZIP CODE:
92223
CAPACITY: 6CENSUS: 6DATE:
08/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:Jonie GatusTIME VISIT/
INSPECTION COMPLETED:
02:00 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
Licensing Program Analysts (LPAs) Magda Malcore and Becky Mann made an unannounced visit to the facility to conduct a required annual inspection. LPAs met with Jonie Gatus, Assisting Administrator, and discussed the purpose of the visit.

The facility is a Residential Care Facility for the Elderly (RCFE) with a license capacity of (6) and a current census of (6) residents in care. LPAs conducted an overall inspection of the facility, which included, but was not limited to, the following:

Operation/Physical Plant: The facility has an infection control plan and emergency disaster plan on file. Indoor and outdoor passageways are free of obstruction. The facility has no swimming pools or similar bodies of water. The facility has sufficient indoor and outdoor activity space. Outdoor activity area is enclosed with a self-latching gate. The facility has sufficient lighting and is maintained at a comfortable temperature. Resident bathroom equipment were operating in a safe and sanitary condition. The hot water temperature in residents' bathrooms measured 105 degrees F. Resident’s bedrooms had beds, bed linen, chairs, sufficient storage space and lighting. Facility has operating carbon monoxide alarms, telephone service and a signal system. The facility has sufficient linen, towels, and personal hygiene items for residents. The facility has posted in a common area, Community Care Licensing complaint poster, Ombudsman poster, Personal Rights, disaster evacuation plan and emergency telephone numbers. Sharps, disinfectants, and cleaning solutions were kept locked and inaccessible to residents in care.
Food Service: Facility kitchen and dining areas are maintained clean. The facility has sufficient non-perishable and perishable food supply for residents in care. The facility's refrigerator and freezer were operating in a healthful manner.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2024
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 4
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: COMPASSION HOME 1
FACILITY NUMBER: 335530023
VISIT DATE: 08/09/2024
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
Care & Supervision: Facility has 24-hour, 7 days a week care staff. Staff working have criminal record clearances through the Department.

Record Review: Staff files reviewed were observed to be complete. Resident files reviewed were observed to be complete. Administrator’s certification and liability insurance were current.

Medical Related Services: Medications were centrally stored in a locked cabinet. LPAs review of resident medications reveals staff did not maintain a complete and current record of resident medications for review. LPAs were provided several lists to find all current medications. Discontinued medications were also listed as current medications. Resident#1 (R1) had a medication on file which was labeled for daily use; however, the Assisting Administrator stated that the medication is to be provided as needed and will have R1's physician update the medication label.

Based on observations and record review, deficiencies are being cited per Title 22, of The California Code of Regulations.

This report was reviewed with the Assisting Administrator and a copy with Appeal Rights was provided to the Assisting Administrator at the conclusion of the visit.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/12/2024 11:20 AM - It Cannot Be Edited


Created By: Magda Malcore On 08/09/2024 at 01:18 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: COMPASSION HOME 1
FACILITY NUMBER: 335530023

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident 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 resident with self-administration, provided all of the following requirements are met: (2) 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 LPA observations, the licensee did not comply with the section cited above by R1's medication was labeled as taken daily; the Assisting Administrator stated it was as needed; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/12/2024
Plan of Correction
1
2
3
4
The Licensee/Administrator shall submit to the licensing agency a written understanding of the regulation cited by 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:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 08/12/2024 11:20 AM - It Cannot Be Edited


Created By: Magda Malcore On 08/09/2024 at 01:18 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: COMPASSION HOME 1
FACILITY NUMBER: 335530023

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observations, the licensee did not comply with the section cited above by not maintaining a complete and current record of resident medications for review; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2024
Plan of Correction
1
2
3
4
The Licensee/Administrator shall submit to the Licensing Agency a written statement of understanding on the regulation cited by 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:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2024


LIC809 (FAS) - (06/04)
Page: 4 of 4