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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800001
Report Date: 10/31/2023
Date Signed: 10/31/2023 01:05:08 PM


Document Has Been Signed on 10/31/2023 01:05 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:TERRA LAGO ASSISTED LIVINGFACILITY NUMBER:
331800001
ADMINISTRATOR:CHOUDRY, SAHERFACILITY TYPE:
740
ADDRESS:84701 VELIERO CTTELEPHONE:
(760) 342-3627
CITY:INDIOSTATE: CAZIP CODE:
92203
CAPACITY:6CENSUS: 5DATE:
10/31/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Staff, Saif Ali ChoudryTIME COMPLETED:
01:15 PM
NARRATIVE
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On 10/31/2023, Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit. LPA was granted entry and met with Staff, Saif Ali Choudry, who was informed of the purpose of the visit. LPA spoke with Administrator Sahar Choudry during the visit, At the time of the visit there was (1) staff and (5) resident present.

The facility is a one story home with attached garage. No firearms or pools are present at the facility. The home has (4) bedrooms and (3) bathrooms. The residents served are elderly adults ages 60 years and above. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted a staff and resident interviews. LPA observed the following:

Infection Control: The LPA observed hand washing stations with hand hygiene supplies. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. The facility has a plan to train staff on infection control guidelines.



Physical Plant: Physical plant was observed to be clean and in good repair. The indoor and outdoor areas were observed to be free of hazards. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to residents. The smoke detector and carbon monoxide were operational, and the hot water temperature was recorded at 106.5F.

Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: TERRA LAGO ASSISTED LIVING
FACILITY NUMBER: 331800001
VISIT DATE: 10/31/2023
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Record Review and Resident/Staff Files: LPA reviewed staff files and training. All staff have criminal clearance. During the visit the one (2) staff at the facility had CPR training which was expired.The administrator re-certification was verified as being submitted, however the Administrator and Assistant- administrator do not have documented training for review during the time of the visit. Deficiency was cited for staff records and plan of correction was created with administrator. Resident files were reviewed all of which posessed required documents.

Health Related Services/ Incidental Medical Services: All client medication was locked in kitchen pantry. LPA reviewed resident medications, all of which were accounted for. One medication, M1 for Resident 1 (R1) did not have a current doctors order at the facility. The administrator was able to provide documentation by the end of the visit. A technical advisory note was documented for all resident medication records to be updated.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. Technical noted was documented for facility to update this to the current department requirements. The last fire drill was conducted April 2023. Deficiency was cited and administrator stated they would conduct Fire Drill by the end of the business day 10/31/23.

An exit interview was conducted where a copy of this report along with deficiency, technical notes and appeal rights were reviewed and provided to Staff, Saif Ali Choudry.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/31/2023 01:05 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: TERRA LAGO ASSISTED LIVING
FACILITY NUMBER: 331800001

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(f)
87412 Personnel Records (f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours...
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above with staff records and facility records that were not at the facility for review during the inspection. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/07/2023
Plan of Correction
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The administrator agreed to send the LPA the staff updated CPR trainings, proof of appropriate staff coverage/ staff schedule, and Proof of updated administrator training for Administrator and S1. This is due by the 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: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 10/31/2023 01:05 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: TERRA LAGO ASSISTED LIVING
FACILITY NUMBER: 331800001

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above with fire drill that had been conducted April of 2023. Thefacility was due for drill in July of 2023 and October of 2023. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2023
Plan of Correction
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The adminsitrator agreed to hold a fire drill by the end of the business day and send proof of this to the LPA by the 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: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4