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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880649
Report Date: 05/06/2022
Date Signed: 05/06/2022 02:23:16 PM

Document Has Been Signed on 05/06/2022 02:23 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:CASA BIENFACILITY NUMBER:
361880649
ADMINISTRATOR:TANDOC, JR. BIENVENIDAFACILITY TYPE:
740
ADDRESS:620 RYAN STTELEPHONE:
(909) 253-1911
CITY:REDLANDSSTATE: CAZIP CODE:
92374
CAPACITY: 6CENSUS: 6DATE:
05/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:48 PM
MET WITH:Bienvenidaja Tandoc- Administrator
TIME COMPLETED:
02:35 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 annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. LPA Gardner met with Administrator Bienvenidaja Tandoc who confirmed that there are currently no cases/exposures of COVID-19 within the facility. At the time of visit there was four (4) staff and six (6) residents present.

LPA Gardner went over COVID-19 best practices for infection control and prevention with Bienvenidaja Tandoc. The facility has a mitigation plan on file with licensing. Residents have hand sanitizer available to them and the bathrooms were stocked with hand soap and paper towels. LPA Gardner observed the facility to have multiple postings throughout the facility for cough etiquette, proper hand washing procedure, and social distancing. LPA Gardner requested to inspect the facility's Personal Protective Equipment (PPE) supply, which was located in the hall closet. The facility has a full 30-day supply of PPE items such as gloves, face shields, gowns, surgical masks, N95 masks, disinfectant, and hand sanitizer. LPA Gardner inquired as to if staff have been fit tested for N95 masks and was told their staff have not been fit tested yet. LPA Gardner will be issuing a Technical Assistance Advisory Note during today's inspection for staff not being fit tested for N95 masks. All residents and staff are practicing all other COVID-19 precautions, which minimize the risk of them contracting COVID-19.

LPA Gardner found that staff (S1) has been at the facility for over five days without being fingerprint cleared to be in the facility. S1 congregates at the facility, helps with groceries, and helps with tasks around the facility. The facility will be issued a citation and a $500 civil penalty for allowing S1 to be at the facility without a fingerprint clearance.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2022
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: CASA BIEN
FACILITY NUMBER: 361880649
VISIT DATE: 05/06/2022
NARRATIVE
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Based on the observations made during today’s visit, one (1) type A deficiency was cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report was discussed and provided to Bienvenidaja Tandoc, along with a copy of the TA Advisory Note, LIC809D, LIC811, and the appeal rights.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/06/2022 02:23 PM - It Cannot Be Edited


Created By: Ryan Gardner On 05/06/2022 at 02:03 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: CASA BIEN
FACILITY NUMBER: 361880649

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(1)
87355.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: (1)Obtain a California clearance or a criminal record exemption as required by the Department or.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in by not obtaining a background clearance for S1 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/07/2022
Plan of Correction
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The administrator has agreed to read regulation 87355 entirely and send LPA a self-certify letter that they have read and understood the regulation. The administrator has agreed get S1 fingerprint cleared and to not allow S1 into the facility until they are fingerprint cleared.
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:Karen Clemons
LICENSING EVALUATOR NAME:Ryan Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2022


LIC809 (FAS) - (06/04)
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