<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530001
Report Date: 07/25/2024
Date Signed: 07/25/2024 04:50:45 PM

Document Has Been Signed on 07/25/2024 04:50 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:BEBING HOME CAREFACILITY NUMBER:
365530001
ADMINISTRATOR/
DIRECTOR:		ZAPANTA, MAX M.FACILITY TYPE:
740
ADDRESS:17446 MADRONE STREETTELEPHONE:
(909) 320-7532
CITY:FONTANASTATE: CAZIP CODE:
92337
CAPACITY: 6CENSUS: 6DATE:
07/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:20 PM
MET WITH:Licensee/Administrator Max ZapantaTIME VISIT/
INSPECTION COMPLETED:
04:55 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
On 07/25/2024 at 12:20 PM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Brown met with Licensee/Administrator Max Zapanta and was granted entry to the facility. At the time of the visit there were two (2) staff present, and six (6) residents present. LPA Brown explained the purpose of the visit to Licensee/Administrator Zapanta.

The facility is a four (4) bedroom, two (2) bathroom home with a kitchen/dining area, living room, activity room, garage, office and laundry area. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) residents of which six (6) can be non-ambulatory residents. The facility has three (3) Hospice Waiver. The current census is six (6) residents. LPA Brown was accompanied by Licensee/Administrator Zapanta 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 Division (CCLD). LPA Brown observed no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 113 degrees Fahrenheit. LPA Brown inspected resident bedrooms; they are equipped with required furniture such as: mattresses, lamps and storage space. LPA Brown observed sufficient lightning. Moreover, LPA Brown observed that bathrooms were clean, and appliances were operating appropriately. LPA Brown observed grab bars and non-skid mat in the resident bathrooms.

The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCLD complaint poster, Ombudsman Poster and the Emergency Disaster plan were posted in a common area. Nightlights were observed in the hallway towards resident bathrooms. ***Continuation in LIC809C ***

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2024
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 6
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: BEBING HOME CARE
FACILITY NUMBER: 365530001
VISIT DATE: 07/25/2024
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
Also, LPA Brown observed Resident #4 (R4) with half bed rails. Licensee/Administrator Zapanta reported that R4 does have written order from R4 physician indicating the need for half bed rail for mobility. Deficiency will be issued. During the tour of the facility, LPA Brown observed a single bed/mattress in the Office area. Office area used as sleeping room for staff. Deficiency will be issued. Moreover, during the tour of the facility, LPA Brown observed one bottle of laundry soap not locked and accessible to residents in care. Deficiency will be issued. LPA Brown observed sufficient furniture and lighting throughout the facility.

There is a cabinet with the resident’s medications locked in the medication cabinet. However, during the tour of the facility, LPA Brown observed medications pre-poured for the whole week for five (5) of six (6) residents at the facility. LPA Brown explained that no medications shall be transferred between containers. Deficiency will be issued. There was a designated storage space for resident/staff files. T

Food Service: Seven (7) days non-perishable and two (2) days perishable food supply observed at the facility.

Care & Supervision: The facility has an administrator present in the facility. LPA Brown observed no staff scheduled to work the night shift as required for facility with dementia residents. Deficiency will be issued.

Record Review: LPA reviewed four (4) resident files for admission agreements, updated physician reports, pre-placement appraisals and needs and services plans. Residents files reviewed were complete. LPA reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test results. LPA found that Staff #3 (S3) does not have Health Screening Report in S3’s facility file. Deficiency will be issued.

Furthermore, during the medication audit, LPA Brown observed Resident #1 (R1), Resident #2 (R2) and Resident #4 (R4) medications were dispensed but R1, R2 and R4 medications administration record was not updated since 07/22/2024. Deficiency will be issued.

An exit interview was conducted where this report (LIC809), LIC809D, and Appeal Rights were discussed and provided to Licensee/Administrator Max Zapanta.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 07/25/2024 04:50 PM - It Cannot Be Edited


Created By: Melody Brown On 07/25/2024 at 03:57 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: BEBING HOME CARE
FACILITY NUMBER: 365530001

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 ensuring the one (1) gallon of detergent soap was locked and not accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/26/2024
Plan of Correction
1
2
3
4
Licensee stated to train all staff on CCR 87309(a) and submit proof to LPA Brown on Plan of Correction (POC) due date.
Type A
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that Staff #3 (S3) completed the reqiuired Health Screening Report which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/26/2024
Plan of Correction
1
2
3
4
Licensee stated to submit proof of Medical Appointment for S3 to complete the required Health Screening Report to LPA Brown on 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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 07/25/2024 04:50 PM - It Cannot Be Edited


Created By: Melody Brown On 07/25/2024 at 03:57 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: BEBING HOME CARE
FACILITY NUMBER: 365530001

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

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 ensuring that medications are not transferred between containers as evidenced of five (5) of six (6) residents medications were pre-poured for the week which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/26/2024
Plan of Correction
1
2
3
4
Licensee stated to train all staff on CCR 87465(h)(5) and submit proof to LPA Brown on Plan of Correction (POC) due date.
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

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 ensuring that Resident #1 (R1), Resident #2 (R2) and Resident #4 (R4) medications were dispensed but R1, R2 and R4 medications administration record was not updated since 07/22/2024 per their physician's order which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/26/2024
Plan of Correction
1
2
3
4
Licensee stated to train all staff on CCR 87465(c)(2) and submit proof to LPA Brown on 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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 07/25/2024 04:50 PM - It Cannot Be Edited


Created By: Melody Brown On 07/25/2024 at 03:57 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: BEBING HOME CARE
FACILITY NUMBER: 365530001

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)(2)(B)
Personal Accommodations and Services
(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage, storage area, shed or similar detached building.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that the office area is not used as sleeping area for staff which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/02/2024
Plan of Correction
1
2
3
4
Licensee stated to remove the single bed in the Office area and submit proof to LPA Brown on Plan of Correction (POC) due date.
Type B
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

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 allowing R4 to half half bed rail and not ensuring that Resident #4 has written order from R4 physician indicating the need for half bed rail for mobility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/02/2024
Plan of Correction
1
2
3
4
Licensee stated to obtain written order from R4's physician indicating the need for half bed rail for mobility and submit to LPA Brown on 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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2024


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 07/25/2024 04:50 PM - It Cannot Be Edited


Created By: Melody Brown On 07/25/2024 at 04:30 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: BEBING HOME CARE
FACILITY NUMBER: 365530001

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(c)(4)(A)
87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:
(4) There is an adequate number of direct care staff to support each resident’s physical, social,
emotional, safety and health care needs as identified in his/her current appraisal.
(A) In addition to requirements specified in Section 87415, Night Supervision, a facility with
fewer than 16 residents shall have at least one night staff person awake and on duty if any
resident with dementia is determined through a pre-admission appraisal, reappraisal or
observation to require awake night supervision.

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 ensuring that there's a staff scheduled to work at night, awake and on duty as required for facility with dementia residents
which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/26/2024
Plan of Correction
1
2
3
4
Licensee stated to submit an updated Personnel Report (LIC500) showing a staff scheduled to work the night shift, awake and on duty as required for facility with dementia residents to LPA Brown on Plan of Correction (POC) due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2024


LIC809 (FAS) - (06/04)
Page: 6 of 6