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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336413086
Report Date: 11/27/2023
Date Signed: 11/27/2023 03:44:39 PM

Document Has Been Signed on 11/27/2023 03:44 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:MC BOARD & CAREFACILITY NUMBER:
336413086
ADMINISTRATOR:MARIA AGUILARFACILITY TYPE:
740
ADDRESS:24259 BRILLANTE DRIVETELEPHONE:
(951) 813-2143
CITY:WILDOMARSTATE: CAZIP CODE:
92595
CAPACITY: 6CENSUS: 5DATE:
11/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Maria Aguilar- AdministratorTIME COMPLETED:
03:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Administrator Maria Aguilar and was granted entry to the facility.

The facility is a Residential Care Facility for the Elderly (RCFE). The facility is a three (3) bedroom, two (2) bathroom home with a kitchen/dining area, living room, and an attached garage. The facility is licensed for a capacity of six (6) non-ambulatory residents, one resident (1) can be bedridden. The current census is five (5) residents. LPA was accompanied by Administrator to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating within the capacity approved by Community Care Licensing (CCL). There are no obstructions to interior and exterior passageways. The facility is maintained at a comfortable temperature. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, and storage space. LPA found that Resident R1’s bedroom does not have a working bedroom light. The only light in R1’s bedroom was the closet light. The facility will be issued a deficiency for not having appropriate lighting in R1’s bedroom. The bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture throughout the facility. LPA measured and observed the water temperature in the bathroom to be at 106.3 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Postings such as the facility license, personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, and toxins were kept inaccessible to the residents in care. The lock for the knives under the kitchen counter is not locked and the knives were accessible to the residents in care. The facility will be issued a deficiency for not locking the knives appropriately. There was a designated storage space for resident/staff files. Medications are kept inside the hallway leading the garage inaccessible to residents. The facility has a first aid kit stored in the hallway leading into the garage.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/27/2023
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 7
Document Has Been Signed on 11/27/2023 03:44 PM - It Cannot Be Edited


Created By: Ryan Gardner On 11/27/2023 at 02:33 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: MC BOARD & CARE
FACILITY NUMBER: 336413086

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/27/2023

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
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Based on interview, observation, and document review, the licensee did not comply with the section cited above evidenced by S1 working at the facility for six (6) months without having a criminal record clearance which poses an immediate health, safety, or personal rights risk to persons in care.
POC Due Date: 11/28/2023
Plan of Correction
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The licensee has agreed to read regulation 87355 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed that S1 will not be present in the facility until S1 has a criminal record clearance. POC is due by 11/28/2023.
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:Ryan Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 11/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/27/2023


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 11/27/2023 03:44 PM - It Cannot Be Edited


Created By: Ryan Gardner On 11/27/2023 at 02:33 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: MC BOARD & CARE
FACILITY NUMBER: 336413086

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(d)
Maintenance and Operation
(d) There shall be lamps or light appropriate for the use of each room and sufficient to ensure the comfort and safety of all persons in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and observation, the licensee did not comply with the section cited above evidenced by R1 not having a light in their bedroom which poses a potential health, safety, or personal rights risk to persons in care.
POC Due Date: 11/28/2023
Plan of Correction
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The licensee has agreed to read regulation 87303 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to ensure R1 has a light in their bedroom. POC is due by 11/28/2023.
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, observation, and document review, the licensee did not comply with the section cited above evidenced by S1, S2, & S3 not having a CPR certification which poses a potential health, safety, or personal rights risk to persons in care.
POC Due Date: 12/04/2023
Plan of Correction
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The licensee has agreed to read HSC 1569.618 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to get S1, S2, and S3 certified in CPR. POC is due by 12/4/2023.
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:Ryan Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 11/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/27/2023


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 11/27/2023 03:44 PM - It Cannot Be Edited


Created By: Ryan Gardner On 11/27/2023 at 02:33 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: MC BOARD & CARE
FACILITY NUMBER: 336413086

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(g)
Personnel Records
(g) All personnel records shall be maintained at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, observation, and document review, the licensee did not comply with the section cited above evidenced by not having staff records for S1, S2, and S3 which poses a potential health, safety, or personal rights risk to persons in care.
POC Due Date: 12/04/2023
Plan of Correction
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The licensee has agreed to read regulation 87412 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to create a staff file for S1, S2, and S3. POC is due by 12/4/2023.
Type B
Section Cited
CCR
87456(a)(2)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, observation, and document review, the licensee did not comply with the section cited above evidenced by not having preadmission appraisals for R2 and R3 which poses a potential health, safety, or personal rights risk to persons in care.
POC Due Date: 12/04/2023
Plan of Correction
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The licensee has agreed to read regulation 87456 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to create preadmission appraisals for R2 and R3. POC is due by 12/4/2023.
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:Ryan Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 11/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/27/2023


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 11/27/2023 03:44 PM - It Cannot Be Edited


Created By: Ryan Gardner On 11/27/2023 at 02:33 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: MC BOARD & CARE
FACILITY NUMBER: 336413086

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87456(a)(3)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (3) Obtain and evaluate a recent medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, observation, and document review, the licensee did not comply with the section cited above evidenced by not having an updated medical assessment for R4 which poses a potential health, safety, or personal rights risk to persons in care.
POC Due Date: 12/11/2023
Plan of Correction
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The licensee has agreed to read regulation 87456 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to obtain an updated medical assessment for R4. POC is due by 12/11/2023.
Type B
Section Cited
HSC
1569.695(e)(2)
Other Provisions
(e) A facility shall have all of the following information readily available to facility staff during an emergency: (2) An appraisal of resident needs and services plan for each resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, observation, and document review, the licensee did not comply with the section cited above evidenced by not having a needs and services plan for R2 and R3 which poses a potential health, safety, or personal rights risk to persons in care.
POC Due Date: 12/04/2023
Plan of Correction
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The licensee has agreed to read HSC 1569.695 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to create a needs and services plan for R2 and R3. POC is due by 12/4/2023.
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:Ryan Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 11/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/27/2023


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 11/27/2023 03:44 PM - It Cannot Be Edited


Created By: Ryan Gardner On 11/27/2023 at 02:33 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: MC BOARD & CARE
FACILITY NUMBER: 336413086

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, observation, and document review, the licensee did not comply with the section cited above evidenced by not making the knives inaccessible to the residents in care which poses a potential health, safety, or personal rights risk to persons in care.
POC Due Date: 11/28/2023
Plan of Correction
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The licensee has agreed to read regulation 87705 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to put a lock on the cabinet to make the knives inaccessible. POC is due by 11/28/2023.
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:Ryan Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 11/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/27/2023


LIC809 (FAS) - (06/04)
Page: 6 of 7
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: MC BOARD & CARE
FACILITY NUMBER: 336413086
VISIT DATE: 11/27/2023
NARRATIVE
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Food Service: Non-perishable and perishable food supply is sufficient for the residents in care.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPA reviewed five (5) resident files for admission agreements, updated physician reports, and needs and services plans. LPA found that Resident R4 does not have an updated medical assessment/physician report. R4’s most recent medical assessment/physician report is dated 6/24/2020. The facility will be issued a deficiency for not having an updated medical assessment/physician report. LPA found that Resident R2 and Resident R3 do not have a preadmission appraisal. The facility will be issued a deficiency for not having a preadmission appraisal. LPA found that Resident R2 and Resident R3 do not have a needs/services plan. The facility will be issued a deficiency for not having needs/services plans. Medications/MARs records were audited and appeared to be dispensed and logged appropriately.

LPA reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA found that Staff S1, Staff S2, and Staff S3 do not have staff files. The facility will be issued a deficiency for not having staff files. LPA found that S1, S2, and S3 do not have CPR certifications. The facility will be issued a deficiency for not having CPR certifications. LPA found that Staff S1 has been working at the facility for six (6) months without a criminal record clearance. Staff S1 admitted to LPA that for the past six (6) months they have been at the facility two (2) to three (3) times a week assisting the residents and helping S3 assist with the residents. The facility will be issued a deficiency for allowing S1 to work at the facility without a criminal record clearance. The facility will be issued a five (5) hundred-dollar civil penalty for allowing S1 to work at the facility for six (6) months without a criminal record clearance.

Based on the observations made during today’s visit, eight (8) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations, along with a five (5) hundred-dollar civil penalty.

An exit interview was conducted, and this report (LIC809), LIC809D forms, LIC811, LIC421BG, and the appeal rights were discussed and provided to Administrator Maria Aguilar.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023
LIC809 (FAS) - (06/04)
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