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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881005
Report Date: 11/04/2024
Date Signed: 11/04/2024 10:09:44 AM

Document Has Been Signed on 11/04/2024 10:09 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:A AND E LOVING SENIOR HOME CARE, INC.FACILITY NUMBER:
361881005
ADMINISTRATOR/
DIRECTOR:		BERNARDO, RUSSELLFACILITY TYPE:
740
ADDRESS:14931 OAKSPRING DRIVETELEPHONE:
(909) 320-7888
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY: 6CENSUS: 5DATE:
11/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:46 AM
MET WITH:Administrator Russell BernardoTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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Licensing Program Analyst (LPAs) Beena Singh and Paola Guerrero made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPAs Beena Singh and Paola Guerrero met with Administrator Russell Bernardo, was granted entry to the facility. At the time of the visit there were two (2) staff present, and four residents present and one (1) was on vacation.

The facility is a five (5) bedroom, three (3) bathroom home with a kitchen/dining area, living room. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) non-ambulatory residents and one (1) may be bedridden and with approved hospice waiver for six (6). The current census is four (4) residents and one (1) resident is on vacation. Three(3) residents are in hospice care, bedridden.

LPA Beena Singh was accompanied by Administrator Bernardo 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 (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstand, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA Beena Singh 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 CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. All sharps are locked. There was a designated office for client/staff files. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care.

***Continuation in LIC809C **

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2024
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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: A AND E LOVING SENIOR HOME CARE, INC.
FACILITY NUMBER: 361881005
VISIT DATE: 11/04/2024
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Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Seven (7) days non-perishable and three (3) days perishable food supply observed at the facility. Facility has a variety of food available for clients. Dishes, cups, and utensils were also stored properly

Care & Supervision: The facility has an administrator present in the facility. LPA Beena Singh observed enough staff to provide care and supervision to the residents in care.

Record Review: LPA Beena Singh reviewed three (3) resident files for admission agreements, updated physician reports, and needs and services plans. The files were complete with updated physician’s reports, admissions agreements, and pre-admissions appraisals. LPA Beena Singh reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA found that staff have CPR training, staff are properly trained in medication, dementia care, and basic training required for an RCFE. Medications/MARs records were audited and appeared to be dispensed appropriately by staff members.

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

Record Review: LPA Beena Singh reviewed three (3) client files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings.

Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (809) was provided to Administrator Russel Bernardo.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2024
LIC809 (FAS) - (06/04)
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