Health inspection·July 10, 2024

PRINTED: 05/13/2026 FORM APPROVED California Department of Public Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ CA240000031 (X3) DATE SURVEY COMPLETED 04/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE POST ACUTE 35253 Avenue H Yucaipa, CA 92399 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A000 Initial Comments ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A000 The following reflects the findings of the California Department of Public Health during a staffing audit visit for 24 randomly selected days from 07/01/2021 to 09/30/2021. Representing the Department: R.P., Associate Governmental Program Analyst. Welfare and Institutions (W&I) Code section 14126.022 sets forth the Department's authority to conduct audits of direct caregiver nursing services provided to residents of skilled nursing facilities, and to establish procedures for conducting such audits through All Facility Letters (AFLs). <http://leginfo.legislature.ca.gov/faces/codes_di splaySection.xhtml? sectionNum=14126.022.&lawCode=WIC> AFL 21-11, setting forth the audit process and guidelines for facilities is available through the following link: <https://www.cdph.ca.gov/Programs/CHCQ/LC P/Pages/AFL-21-11.aspx> Health and Safety Code (HSC) 1337-1338.5, sets forth the requirements for Certified Nurse Assistants is available through the following link: <https://leginfo.legislature.ca.gov/faces/codes_ displayText.xhtml? division=2.&chapter=2 .&lawCode=HSC&article=9> W&I section 14126.022 requires the Department to assess an administrative penalty to a SNF if the Department determines that the SNF fails to meet the DHPPD requirements pursuant to HSC sections 1276.5 Licensing and Certification Division LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE STATE FORM 6899 5I8H11 TITLE (X6) DATE If continuation sheet 1 of 6 PRINTED: 05/13/2026 FORM APPROVED California Department of Public Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: CA240000031 (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ (X3) DATE SURVEY COMPLETED 04/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE POST ACUTE 35253 Avenue H Yucaipa, CA 92399 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE or 1276.65. The Department shall assess an administrative penalty to any facility that fails to meet the applicable standard for staffing requirements on any given day. The applicable standard is 3.5 DHPPD and 2.4 DHPPD (CNA), unless an approved Workforce Shortage or Patient Needs Waiver is granted. The statute was not met as evidenced by the following findings: Final Audit Result: Total Distinct Non-Compliant Day(s) = 19 Date 3.5 2.4 07/04/2021 *2.24* *1.30* 07/12/2021 *3.27* *2.03* 07/15/2021 *2.78* *1.72* 07/19/2021 *3.14* *1.94* 07/21/2021 3.59 *2.11* 07/26/2021 *2.83* *1.40* 07/30/2021 *3.44* *1.98* 08/01/2021 *2.39* *1.68* 08/03/2021 3.60 *2.34* 08/04/2021 *3.15* *2.19* 08/05/2021 3.54 *2.20* 08/07/2021 *2.99* *1.95* 08/13/2021 *2.55* *1.69* 08/17/2021 3.55 2.43 08/18/2021 3.55 2.40 08/21/2021 *3.35* *2.18* 08/24/2021 3.64 2.43 08/29/2021 *3.02* *1.71* 08/31/2021 3.58 *2.20* 09/07/2021 3.54 *2.18* 09/15/2021 3.62 *2.30* 09/23/2021 3.77 2.40 09/26/2021 *3.26* *1.92* 09/29/2021 4.04 2.61 *x.xx* = non-compliant date Licensing and Certification Division STATE FORM 6899 5I8H11 If continuation sheet 2 of 6 PRINTED: 05/13/2026 FORM APPROVED California Department of Public Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ CA240000031 (X3) DATE SURVEY COMPLETED 04/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE POST ACUTE 35253 Avenue H Yucaipa, CA 92399 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A200 HSC 1276.65(c)(1)(B) SAS - 3.5 Standard ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A200 (B) Effective July 1, 2018, skilled nursing facilities, except those skilled nursing facilities that are a distinct part of a general acute care facility or a state-owned hospital or developmental center, shall have a minimum number of direct care services hours of 3.5 per patient day, except as set forth in Section 1276.9. This Statute is not met as evidenced by: Facility failed to meet 3.5 Direct Care Service Hours Per Patient Day (DHPPD), Pursuant to HSC 1276.65(c)(1)(B) for 13 of 24 days. The statute was not met as evidenced by the following findings: The total number of actual direct care nursing hours performed by direct caregivers per patient day divided by the average census during the patient day failed to meet DHPPD Staffing Standard(s). Payroll records were incomplete, illegible or inaccurate. Time spent providing nursing services could not be verified. Failure to provide the information has resulted in the exclusion of all service hours for such employees. Employee(s) failed to delineate time spent providing nursing services to skilled nursing care patients, as defined in HSC section 1276.65 and CCR Title 22, section 72309, section 72311 and section 72315, while assigned to perform other duties other than direct care. Time spent providing nursing services could Licensing and Certification Division STATE FORM 6899 5I8H11 If continuation sheet 3 of 6 PRINTED: 05/13/2026 FORM APPROVED California Department of Public Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ CA240000031 (X3) DATE SURVEY COMPLETED 04/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE POST ACUTE 35253 Avenue H Yucaipa, CA 92399 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE not be verified. Failure to provide the information has resulted in the exclusion of all service hours for such employees. Per HSC, section 1337.2 (g) " ...It shall be unlawful for any person not certified under this article to hold himself or herself out to be a certified nurse assistant. " CDPH found staff with lapsed, suspended, expired, or revoked certification(s) and/or nurse assistants in training without active certification(s). This necessitated excluding all CNA service hours for such employees. Facility failed to replace staff that did not work as scheduled, and/or did not schedule to meet the minimum staffing requirements. A205 HSC 1276.65(c)(1)(C) SAS - 2.4 Standard A205 (C) Skilled nursing facilities shall have a minimum of 2.4 hours per patient day for certified nurse assistants in order to meet the requirements in subparagraph (B). Licensing and Certification Division STATE FORM 6899 5I8H11 If continuation sheet 4 of 6 PRINTED: 05/13/2026 FORM APPROVED California Department of Public Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: CA240000031 (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ (X3) DATE SURVEY COMPLETED 04/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE POST ACUTE 35253 Avenue H Yucaipa, CA 92399 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This Statute is not met as evidenced by: Facility Failed to meet 2.4 Direct Care Service Hours Per Patient Day (DHPPD) performed by certified nurse assistants, pursuant to HSC 1276.65(c)(1)(C) for 19 out of 24 days. The statute was not met as evidenced by the following findings: The total number of actual direct care nursing hours performed by direct caregivers per patient day divided by the average census during the patient day failed to meet DHPPD Staffing Standard(s). Per HSC, section 1337.2 (g) " ...It shall be unlawful for any person not certified under this article to hold himself or herself out to be a certified nurse assistant. " CDPH found staff with lapsed, suspended, expired, or revoked certification(s) and/or nurse assistants in training without active certification(s). This necessitated excluding all CNA service hours for such employees. Payroll records were incomplete, illegible or inaccurate. Time spent providing nursing services could not be verified. Failure to provide the information has resulted in the exclusion of all service hours for such employees. Time spent providing nursing services could not be verified. Failure to provide the information has resulted in the exclusion of all service hours for such employees. Facility failed to replace staff that did not work as scheduled, and/or did not schedule to meet the minimum staffing requirements. Licensing and Certification Division STATE FORM 6899 5I8H11 If continuation sheet 5 of 6 PRINTED: 05/13/2026 FORM APPROVED California Department of Public Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: CA240000031 (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ (X3) DATE SURVEY COMPLETED 04/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE POST ACUTE 35253 Avenue H Yucaipa, CA 92399 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Licensing and Certification Division STATE FORM 6899 5I8H11 If continuation sheet 6 of 6