361881034-2-25-2025-56-AS-SRAZ-DE8RYX-20250225122705

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361881034
Report Date: 02/25/2025
Date Signed: 02/25/2025 12:27:15 PM

Document Has Been Signed on 02/25/2025 12:27 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	BROOKDALE LOMA LINDA		FACILITY NUMBER:	361881034
ADMINISTRATOR/ DIRECTOR:	LUJAN, MARITZA		FACILITY TYPE:	740
ADDRESS:	25585 VAN LEUVEN STREET		TELEPHONE:	(909) 796-5421
CITY:	LOMA LINDA	STATE: CA	ZIP CODE:	92354
CAPACITY: 220		CENSUS: 106	DATE:	02/25/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:45 AM
MET WITH:	Executive Director Maritza Lujan		TIME VISIT/ INSPECTION COMPLETED:	12:35 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Licensing Program Analysts (LPAs) Sarina Ramirez and Eldin Serrano made an unannounced visit to the facility to conduct a required annual inspection. LPAs met Executive Director Maritza Lujan and discussed the purpose of the visit. The facility is a Residential Care Facility for Elderly (RCFE) with a license capacity of (220), and a current census of (106). LPAs conducted a general inspection of the facility, which included, but was not limited to, the following:

Physical Plant: Indoor and outdoor passageways were kept free of obstruction. The facility has no swimming pool or similar bodies of water. The facility has sufficient space for resident activities. Five (5) resident bedrooms were inspected. Five (5) resident’s bathrooms were inspected, hot water temperatures measured 110.1 degrees F. The facility is equipped with operating smoke/carbon monoxide alarms, the facility was recently inspected by the Fire Department on 02/14/25. Facility has operating laundry equipment, and telephone service. The facility has posted in a common area, personal rights, facility sketch, the Community Care Licensing complaint poster, Ombudsman poster, menu, activities, and license. Cleaning supplies were kept inaccessible to residents in care.

Food Service: Kitchen and dining areas were maintained cleaned. Perishable food supply is sufficient for number of residents in care, however nonperishable food supply is not sufficient for a seven (7) day supply, deficiency will be issued . Facility refrigerators and freezers were maintained in operating condition. The facility has posted a monthly menu. Sharps were not kept locked, deficiency will be issued.

Continuation on LIC809-C

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/25/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025

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 3

Document Has Been Signed on 02/25/2025 12:27 PM - It Cannot Be Edited

Created By: Sarina Ramirez On 02/25/2025 at 11:50 AM

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: BROOKDALE LOMA LINDA	FACILITY NUMBER: 361881034
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space and Access

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above by having sharps accessible and not locked in the kitchen which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/28/2025
	Plan of Correction
1 2 3 4	LPA Serrano observed Maintanence Director lock knives in a cabinet in the kitchen. Administrator has agreed to send proof of a lock box for sharps to LPA by POC due date.

Type A

Section Cited

CCR

87555(b)(26)

General Food Service Requirements

(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above by not having seven (7) days of non perishables which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/26/2025
	Plan of Correction
1 2 3 4	Administrator has agreed to send proof of purchase for non perishables to LPA 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:

Sarina Ramirez

LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: BROOKDALE LOMA LINDA	FACILITY NUMBER: 361881034
	VISIT DATE: 02/25/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Health Related services: LPAs reviewed (6) resident medications. Resident’s medications are labeled and centrally stored in a locked room.

Record Review: Ten (10) resident files reviewed were observed to be complete. Eight (8) staff files reviewed were observed to be complete. The facility has an emergency and disaster plan on file; last disaster drill was completed on 02/20/25.

Based on LPAs observations and records reviewed, deficiencies are being cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted where this report (LIC809) and LIC 809D was discussed to Executive Director Maritza Lujan . Copies of the reports were provided with appeal rights to the Executive Director at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/25/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025

LIC809 (FAS) - (06/04)

Page: 3 of 3