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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530071
Report Date: 01/07/2025
Date Signed: 01/07/2025 03:21:54 PM

Document Has Been Signed on 01/07/2025 03:21 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:CTR HOME CARE LLCFACILITY NUMBER:
365530071
ADMINISTRATOR/
DIRECTOR:
PEREZ, APOLINARIOFACILITY TYPE:
740
ADDRESS:11490 RICHMONT ROADTELEPHONE:
(909) 894-3852
CITY:LOMA LINDASTATE: CAZIP CODE:
92354
CAPACITY: 6CENSUS: 5DATE:
01/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Administrator Apolinario PerezTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sarina Ramirez made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Administrator Apolinario Perez, and discussed the purpose of the visit.

The facility is a Residential Care Facility for the Elderly (RCFE) with a license capacity of (6), a current census of (5). LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:

Physical Plant/Environment: Indoor and outdoor passageways are free of obstruction. The facility does not have a swimming pool or similar bodies of water. The facility has sufficient lighting and is maintained at a comfortable temperature. The facility has sufficient indoor and outdoor space for resident activities The facility is equipped with operating smoke detectors/carbon monoxide alarms, working laundry equipment, and telephone service. Resident’s showers, toilets, and hand washing areas were operating properly. The hot water temperature in two (2) resident bathrooms measured between 106 and 107 degrees F. Four (4) resident’s bedrooms had beds, bed linen, dresser, storage space and sufficient lighting. The facility has sufficient linens, towels, and personal hygiene items for residents. The facility has posted in a common area, facility license, administrator certificate, facility sketch, activity schedule, menu, resident rights, emergency telephone numbers, CCLD complaint poster, and Ombudsman poster.

Food Service: Facility kitchen and dining area are maintained clean. The facility has sufficient non-perishable and perishable food supply for residents in care. Sharps and chemicals were kept locked and inaccessible to residents in care.

Continuation on LIC – 809C:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2025
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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Document Has Been Signed on 01/07/2025 03:21 PM - It Cannot Be Edited


Created By: Sarina Ramirez On 01/07/2025 at 03:02 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: CTR HOME CARE LLC

FACILITY NUMBER: 365530071

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 01/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
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Based on observation, interview, and record review, the licensee did not comply with the section cited above by Staff #1 and #2 did not have health screenings prior to working which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/10/2025
Plan of Correction
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Licensee agreed to send proof of health screening for S#1, #2, and #3 to LPA 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:Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/07/2025


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: CTR HOME CARE LLC
FACILITY NUMBER: 365530071
VISIT DATE: 01/07/2025
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Care & Supervision: Facility has 24-hour/7days a week care staff. Facility staff have current CPR/first aid training.

Medical Related Services: Resident’s medications are labeled and centrally stored in a locked cabinet.

Record Review: Four (4) Staff files reviewed were observed to be incomplete, Staff #1 and #2 do not have health screenings; deficiency will be issued. Three (3) Resident files reviewed were observed to be complete.

Based on observations and record review deficiency was cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report along with LIC 809D and appeal rights were discussed and copies provided to Administrator Apolinario Perez.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025
LIC809 (FAS) - (06/04)
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