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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530185
Report Date: 09/21/2024
Date Signed: 09/21/2024 03:52:38 PM

Document Has Been Signed on 09/21/2024 03:52 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:ASSISTED LIVING AND MEMORY CARE BY INSPIRATIONSFACILITY NUMBER:
335530185
ADMINISTRATOR/
DIRECTOR:		GARCIA, DOMINICFACILITY TYPE:
740
ADDRESS:1048 LA VAUGHN CIRCLETELEPHONE:
(951) 317-4773
CITY:CORONASTATE: CAZIP CODE:
92881
CAPACITY: 6CENSUS: 6DATE:
09/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Lizette AlvarezTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On 09/21/2024 at 11:15 AM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Brown met with a staff and was granted entry to the facility. At the time of the visit there were two (2) staffs present, and six (6) residents present. LPA Brown met with Administrator Dominic Garcia and LPA Brown informed Administrator Garcia of the purpose of the visit. Administrator Garcia left during the visit due to personal appointment. Administrator Garcia authorized Staff #4 (S4) to receive and sign the reports of the visit today. LPA Brown explained the purpose of the visit to Staff #2 (S2) and S4..

The facility is a five (5) bedroom, three (3) bathroom home with a kitchen/dining area, living room, laundry area and attached three (3) car garage. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) residents of which six (6) can be non-ambulatory residents where one (1) may be bedridden. The facility has six (6) Hospice Waiver. The current census is six (6) residents. LPA Brown was accompanied by S2 to conduct a general overall inspection, which included, but was not limited to the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). LPA Brown observed no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 74 degrees Fahrenheit. LPA Brown inspected resident bedrooms; they are equipped with required furniture such as: mattresses, lamps and storage space. LPA Brown observed sufficient lightning. Moreover, LPA Brown observed that bathrooms were clean, and appliances were operating appropriately. LPA Brown measured the hot water at residents shared bathroom and LPA Brown observed 108 degrees Fahrenheit. LPA Brown observed grab bars and non-skid mat in the resident bathrooms. ***Continuation in LIC809C ***

NAME OF LICENSING PROGRAM MANAGER: Efren Malagon
NAME OF LICENSING PROGRAM ANALYST: Melody Brown
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2024
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: ASSISTED LIVING AND MEMORY CARE BY INSPIRATIONS
FACILITY NUMBER: 335530185
VISIT DATE: 09/21/2024
NARRATIVE
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Also,LPA Brown observed Resident #2 (R2) has half bed rails. But per documents review and staff interview, R2 does not have a written order from R2 physician indicating the need for half bed rail for mobility. Deficiency will be issued. Moreover, LPA Brown observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCLD complaint poster, Ombudsman Poster and the Emergency Disaster plan were posted in a common area. Furthermore, LPA Brown observed Emergency Food and Water at the facilities.

Food Service: Seven (7) days non-perishable and three (3) days perishable food supply observed at the facility.

Care & Supervision: The facility has a certified administrator. However, LPA Brown observed no sufficient number of staff to provide care and supervision to the residents in care as there's no staff scheduled to work the night shift, awake and on duty as required for facility with dementia residents. Deficiency will be issued.

Record Review: LPA Brown observed no liability insurance at the facility. Deficiency will be issued. LPA Brown observed no emergency - fire or earthquake drill conducted at the facility at least quarterly. Deficiency will be issued.

LPA Brown reviewed four (4) resident files for admission agreements, updated physician reports, pre-placement appraisal, centrally stored medication list and needs and services plans. LPA Brown observed Resident #1 (R1), Resident #2 (R2) and Resident #3 (R3) have physician report but R1, R2 and R3's physician report do not have the required physician signature and signature date. Deficiency will be issued. In addition, LPA Brown observed Resident #1 (R1), Resident #2 (R2), Resident #3 (R3) and Resident #4 (R4) have Admission Agreement in their facility file but the required signature page were not complete or missing and other pages are also missing. Deficiency will be issued. LPA Brown reviewed four (4) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test results. LPA Brown observed that documents reviewed were complete.

An exit interview was conducted where this report (LIC809), LIC809D, and Appeal Rights were discussed and provided to staff Lizette Alvarez.

NAME OF LICENSING PROGRAM MANAGER: Efren Malagon
NAME OF LICENSING PROGRAM ANALYST: Melody Brown
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2024
LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 09/21/2024 03:52 PM - It Cannot Be Edited


Created By: Melody Brown On 09/21/2024 at 02:57 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: ASSISTED LIVING AND MEMORY CARE BY INSPIRATIONS
FACILITY NUMBER: 335530185

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type A
Section Cited
CCR
87705(c)(4)(A)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident's physical, social, emotional, safety and health care needs as identified in his/her current appraisal. (A) In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal or observation to require awake night supervision.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that there's a staff scheduled to work the night shift, awake and on duty as required for facility with dementia residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/22/2024
Plan of Correction
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Licensee stated to submit an updated Personnel Report (LIC500) or updated staff work schedule showing a staff scheduled to work at night, awake and on duty as required for facility with dementia residents to LPA Brown on Plan of Correction (POC) due date.
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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2024


LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 09/21/2024 03:52 PM - It Cannot Be Edited


Created By: Melody Brown On 09/21/2024 at 02:57 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: ASSISTED LIVING AND MEMORY CARE BY INSPIRATIONS
FACILITY NUMBER: 335530185

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that the facility has the required liability insurance which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/27/2024
Plan of Correction
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Licensee stated to submit a copy of the required liability insurance for the facility to LPA Brown on Plan of Correction (POC) due date.
Deficiency Dismissed
Type B
Section Cited
CCR
87507(c)
Admission Agreements
(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above by not ensuring that Resident #1 (R1), Resident #2 (R2), Resident #3 (R3) and Resident #4 (R4) have Admission Agreement in their facility file but the required signature page were not complete or missing and other pages are missing as well which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/27/2024
Plan of Correction
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Licensee stated to submit the required completed copy of R1, R2, R3 and R4 Admission Agreement to LPA Brown 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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2024


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 09/21/2024 03:52 PM - It Cannot Be Edited


Created By: Melody Brown On 09/21/2024 at 02:57 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: ASSISTED LIVING AND MEMORY CARE BY INSPIRATIONS
FACILITY NUMBER: 335530185

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above by not conducting the required emergency drill quarterly at the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/27/2024
Plan of Correction
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Licensee stated to conduct the required emergency drill starting this month and every quarter and submit proof to LPA Brown on Plan of Correction (POC) due date.
Type B
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above by allowing Resident #2 (R2) to have half bed rail but there's no doctor's written order from R2 Physician indicating the need for half bed rail for mobility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2024
Plan of Correction
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Licensee stated to submit a copy of R2 written order from R2 physician indicating the need for half bed rail for mobility to LPA Brown on POC due date. Or, remove R2 half bed rail and submit proof to LPA Brown 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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2024


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 09/21/2024 03:52 PM - It Cannot Be Edited


Created By: Melody Brown On 09/21/2024 at 03:03 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: ASSISTED LIVING AND MEMORY CARE BY INSPIRATIONS
FACILITY NUMBER: 335530185

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type A
Section Cited
CCR
87458(a)
87458 Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that Resident #1 (R1), Resident #2 (R2) and Resident #3 (R3) have a completed Medical Assessment or Physician Report from R1, R2 and R3 physician prior to a person's acceptance as a resident to the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/22/2024
Plan of Correction
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Licensee stated to submit the required completed Medical Assessment for R1, R2 and R3 to LPA Brown on Plan of Correction (POC) due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2024


LIC809 (FAS) - (06/04)
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