Mira Loma Senior Care Home

Allegation investigated: Facility staff did not assist resident with hygiene as needed. Facility staff did not assist resident with incontinence care as needed.

Licensing Program Analyst (LPA) Mary Rico conducted an unannounced visit to investigate and deliver the findings on the allegations listed above. LPA met with staff Luz Hernandez and explained the purpose of today’s visit. The investigation consisted of staff interviews, resident interviews and record review. The Licensee was also contacted and informed about today's visit. For the allegation, Facility staff did not assist resident with hygiene as needed. During residents’ interviews, 3 out of the 3 residents stated staff assist with their hygiene and provide reminders when needed. During staff interviews, 3 out of the 3 staff stated hygiene is provided in the morning and night. For the allegation, Facility staff did not assist resident with incontinence care as needed. During residents’ interview, 2 out of the 3 residents stated staff change their brief on time. Furthermore, 1 out of the 3 residents stated they are independent and do not require assistance to the bathroom. During resident interviews, 3 out of the 3 staff stated they change residents brief every two to three hours or as needed. Unsubstantiated For the allegation, Facility staff did not assist resident with incontinence care as needed. During residents’ interview, 2 out of the 3 residents stated staff change their brief on time. Furthermore, 1 out of the 3 residents stated they are independent and do not require assistance to the bathroom. During resident interviews, 3 out of the 3 staff stated they change residents brief every two to three hours or as needed. Based on the evidence found during the investigation, the two (2) allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. 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 (LIC9099) was discussed and provided to staff Luz Hernandez.the state’s words, verbatim · CDSS document, Mar 6, 2026 · control 56-AS-20250825124455

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Mary Rico made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection LPA met with staff Luz Hernandez and was granted entry to the facility. Licensed capacity is (10) current census (8). LPA was accompanied by staff Luz Hernandez , 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 resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA 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 residents in care. Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Facility has a variety of food available for residents . Dishes, cups, and utensils were also stored properly. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. Record Review: LPA reviewed (3) resident file for admission agreements, updated physician reports, and needs and services plans. LPA also verified (3) resident's medications. LPA also reviewed (1) staff files for First Aid/CPR certification, criminal record clearance, training's, and health screening. 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 (LIC809) was discussed and provided to staff Luz Hernandez.the state’s words, verbatim · CDSS document, Mar 6, 2026

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Mary Rico conducted an announced visit to the facility for the purpose of increasing the capacity. LPA was greeted and granted entrance by Administrator Camille Pinero. Per the LIC200, Licensee requested for the capacity increase from five (5) non- ambulatory to nine (9) non- ambulatory. The fire clearance request was approved on 10/6/2025 for nine (9)non- ambulatory residents. The licensee was advised that the noted designated capacity for each room is to remain in compliance. LPA observed that the residents bedrooms were appropriately furnished and had functional lighting. The physical plant is ready for an increase in capacity. LPA will update the facility's file and issue a new license stating change in capacity. An exit interview was conducted where this report LIC809 was discussed and provided to the Administrator Camille Pinero.the state’s words, verbatim · CDSS document, Nov 3, 2025

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Mary Rico conducted an unannounced case management visit pertaining to complaint control number 56-AS-20250825124455 . LPA Rico met with staff Divyashi Fnu and explained the purpose of the visit. The Administrator Camille Pinero was contacted and informed about today’s visit. During facility tour, LPA Rico observed the facility had converted their garage into a hallway with two additional bedrooms. LPA Rico observed one bedroom to be occupied by one resident (R1). The Administrator informed LPA that they have been working with the city and their local fire department for permits. As of 9/2/2025, the facility has not submitted an updated LIC200, along with their updated facility sketch to Community Care Licensing. In addition, the facility does have a valid fire clearance for the additional rooms. A deficiency will be issued. Based of on the information gathered today’s visit one (1) deficiency and five hundred dollars (500.00) civil penalty was cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809) (LIC809D)(LIC421IM) was discussed on the phone with Administrator Camille Pinero and a copy was provided to staff Divyashi Fnu.Along with a copy of appeal rights.the state’s words, verbatim · CDSS document, Sep 2, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87207 · Plan of correction due date: Sep 3, 2025

87207 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. Based on observation, interview and record review, the licensee did not comply with the section cited above by having an approved fire clearance for additonal rooms, and not licensed by CCL which poses a immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 2, 2025

Plan of correction: The Licensee stated they will submit their LIC200 and obtain a new fire clearance for their additional rooms. Licensee will also move R1 to a room that has been licensed and cleared from the fire department. POC due date 9/2/2025.

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Mary Rico conducted an announced visit to complete a pre-licensing inspection and component III. LPA met with Licensee/Administrator Camille Pinero. The pending application is for a change of ownership for a Residential Care Facility for the Elderly (RCFE). The approved fire clearance granted for five (5) non-Ambulatory and one (1) bed-ridden residents on 2/20/2025. The interior and exterior were toured of the pending facility. Overall, the pending facility is clean and in good condition. LPA observed all bedrooms to be appropriately furnished with adequate lighting. Bathroom toilets, showers have grab bars and non-skid mats. LPA observed food storage and preparation areas to be clean and sanitary. Refrigerator and freezer temperatures are maintained at appropriate temperatures. All appliances are clean and operating properly. There is a sufficient supply of linens, towels, and personal hygiene items. The first aid kit was reviewed; all items are present including a First Aid Manual. LPA observed an adequate supply of recreation and leisure items and activities. The backyard is completely enclosed with functioning gate to exit to front yard. Outdoor space is suitable for resident use that includes a covered patio with a table and chairs. LPA observed the fire extinguishers to be recently serviced and completely charged. Smoke alarms and carbon monoxide detectors are present and functional. Medications will be centrally stored and secured in a locked office. All hazardous materials such as, cleaning, and disinfecting supplies, knives and other sharps are locked and inaccessible to residents. All required forms are posted in a common area. Pre-Licensing Inspection is complete and has no deficiencies. No corrections need to be made. An exit interview was conducted where this report was discussed and provided to Licensee/ Administrator Camille Pinero.the state’s words, verbatim · CDSS document, Mar 20, 2025

Type of visit: Office

Facility Type: RCFE Application Type: CHOW Capacity: 6 Census (if any clients in care): 5 Interview Method: Telephone interview On 2/25/2025, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Feb 25, 2025