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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880649
Report Date: 04/22/2024
Date Signed: 04/22/2024 05:09:08 PM

Document Has Been Signed on 04/22/2024 05:09 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:CASA BIENFACILITY NUMBER:
361880649
ADMINISTRATOR/
DIRECTOR:		TANDOC, JR. BIENVENIDAFACILITY TYPE:
740
ADDRESS:620 RYAN STTELEPHONE:
(909) 253-1911
CITY:REDLANDSSTATE: CAZIP CODE:
92374
CAPACITY: 6CENSUS: 5DATE:
04/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Bienvenida Tandoc Jr - AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Bienvenida Tandoc Jr, 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 (5) residents in care. The facility has a hospice waiver for (2) residents. LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:

Physical Plant/Environment: LPA observed that the Licensee is not operating within the limitation of their license. The Redlands Fire Department approved the facility license for six (6) Ambulatory residents; however, the five (5) residents in care are unable to ambulate without staff assistance and/or without the assistance of a mechanical aid.
Indoor and outdoor passageways are free of obstruction. The facility has no swimming pools or similar bodies of water. Outdoor shaded area is sufficient for resident activities and is enclosed with a self-latching gate.The facility has sufficient lighting and is maintained at a comfortable temperature.
Resident’s showers, toilets, and hand washing areas were operating in a safe and sanitary condition. The hot water temperature in residents' bathrooms measured 107 degrees F. The facility has operating carbon monoxide alarms. 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.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 04/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/22/2024
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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CASA BIEN
FACILITY NUMBER: 361880649
VISIT DATE: 04/22/2024
NARRATIVE
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Food Service: The facility kitchen and dining areas are maintained clean. The facility has sufficient non-perishable and perishable food supply for residents in care. Cleaning solutions and other toxins are store away from the food supply.

Care & Supervision: The facility has 24-hour, 7 days a week care staff.

Record Review: LPA review of staff files reveal, staff#1 (S1) and staff#2 (S2) did not have current first aid/CPR training on file. LPA review of resident files reveal, resident #1 (R1) did not have a physician's report/medical assessment on file for review. LPA record review also reveals an emergency drill with staff has not been conducted quarterly. The facility’s last drill was conducted was on 4/1/23.

Medical Related Services: Resident’s medications are centrally stored and kept locked.

Based on LPA observations and record review, deficiencies are being cited per Title 22, of The California Code of Regulations and Health and Safety Codes. An immediate civil penalty is also being assessed today and fees will continue to accrue if the deficiency is not corrected.

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

DATE: 04/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 04/22/2024 05:09 PM - It Cannot Be Edited


Created By: Magda Malcore On 04/22/2024 at 03:22 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: CASA BIEN
FACILITY NUMBER: 361880649

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Fire Clearance
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Type A
Section Cited
CCR
87202(a)(1)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (1) Nonambulatory persons.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations, the licensee did not comply with the section cited above by five (5) residents in care are unable to ambulate without staff assistance and/or without the assistance of a mechanical aides which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2024
Plan of Correction
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The Licensee/Administrator shall submit to the licensing agency a request for change of ambulatory status and provide a statement that the local fire department was notified of their current non-ambulatory status by 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:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/22/2024 05:09 PM - It Cannot Be Edited


Created By: Magda Malcore On 04/22/2024 at 03:22 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: CASA BIEN
FACILITY NUMBER: 361880649

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2024

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
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Based on LPA record review, the licensee did not comply with the section cited above by Staff #1(S1) and Staff #2 (S2) did not have current first aid/CPR training, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2024
Plan of Correction
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Licensee/Administrator shall submit to the licensing agency documentation of current training by POC due date.
Type B
Section Cited
CCR
87458(a)
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 LPA record review, the licensee did not comply with the section cited above by resident #1 (R1) did not have a physician's report/medical assessment on file for review, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2024
Plan of Correction
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The Licensee/Administrator shall submit to the Licensing Agency documentation of R1's physician's report/medical assessment by 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:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 04/22/2024 05:09 PM - It Cannot Be Edited


Created By: Magda Malcore On 04/22/2024 at 04:14 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: CASA BIEN
FACILITY NUMBER: 361880649

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
(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...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 LPA record review, the licensee did not comply with the section cited above by not conducting at a minimum a quarterly drill. The facility’s last drill was conducted on 4/1/23, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2024
Plan of Correction
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The Licensee/Administrator shall submit to the Licensing Agency documentation of a current drill by 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:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2024


LIC809 (FAS) - (06/04)
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