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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800064
Report Date: 08/11/2023
Date Signed: 08/11/2023 02:40:22 PM


Document Has Been Signed on 08/11/2023 02:40 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:SACRED HEART-STOYVIEWFACILITY NUMBER:
331800064
ADMINISTRATOR:CERDA, YAZMINFACILITY TYPE:
740
ADDRESS:37189 STOYVIEW CIRCLETELEPHONE:
(951) 698-4258
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY:6CENSUS: 3DATE:
08/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:49 PM
MET WITH:Administrator Yazmin CerdaTIME COMPLETED:
02:45 PM
NARRATIVE
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On 8/11/2023, Licensing Program Analyst (LPA) Janette Romero arrived unannounced at the facility to conduct an annual required visit. LPA was greeted and granted entry by Caregiver Maria Espinoza who was informed of the purpose of visit. Administrator Yazmin Cerda arrived during the visit. The facility is approved for 6 non-ambulatory residents, of which one (1) may be bedridden. The facility has a hospice waiver for four (4) residents. During the visit, there was four (4) residents and (2) staff present.

LPA toured the facility’s interior and exterior, and observed the following:

Kitchen: LPA observed kitchen area to be clean. Food is stored in a safe and healthful manner. LPA observed the facility had a 2-day supply of perishable foods and 7-day of non-perishable food items.

Dining and Living room: LPA toured the dining and living/family room area. LPA observed area to be clean and furniture in good condition. LPA observed plenty of board games and activities available for residents in care. During the visit, LPA observed residents eating lunch and resting in their rooms. Carbon monoxide and smoke detector were tested and functioning properly.



Bedrooms: Resident bedrooms were each furnished with a bed, chair, closet, clothing storage and lighting.

Continued on LIC809-C..
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2023
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 3


Document Has Been Signed on 08/11/2023 02:40 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: SACRED HEART-STOYVIEW
FACILITY NUMBER: 331800064

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(b)(3)
(b) If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted to assist the resident with self-administration of his/her PRN medication.
(3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in due to LPA observing Resident #1's PRN MAR "date" column had whiteout markings, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/21/2023
Plan of Correction
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Licensee agreed to provide staff training regarding PRN medication dispensing and documentation. Proof of correction to be submitted to CCLD by close of business on POC due date.
Type B
Section Cited
CCR
87411(a)(1)
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement was not met as evidenced by:

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 due to record review revealing Staff #1 does not possess current CPR/first aid certification, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/21/2023
Plan of Correction
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Licensee agreed to request Staff #1 to renew their CPR/First Aid certification and provide proof of correction to CCLD by close of business 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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SACRED HEART-STOYVIEW
FACILITY NUMBER: 331800064
VISIT DATE: 08/11/2023
NARRATIVE
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Bathrooms: Bathrooms have a working toilet, wash basin, and were equipped with a grab bar in the shower. The hot water temperatures measured at 121- and 122-degrees Fahrenheit. The facility has clean towels, blankets, and linen, available in different colors for the residents in care.

Laundry/Garage: LPA toured the laundry room and garage. Washing machine and dryer are in good repair. Emergency food supplies, water, additional hygiene supplies, and incontinent supplies are stored in the garage.

Yard/Outside Area: All outdoor pathways were free of obstructions. No bodies of water were observed. There were no firearms or ammunition observed at the facility, and LPA was informed the facility will not store firearms or ammunition on the premises.

Records: Staff present have a criminal record clearance on file and are associated to the facility. Record review revealed CPR/first aid certification for Staff #1 expired as of 7/26/2023. Deficiency cited.

Centrally Stored Medications: LPA observed a first aid kit with required components. Medications were secured in a medicine cart stored in a hallway closet. LPA reviewed physical medications for Resident #1 (R1) and Resident #2 as well as Medication Administration Record (MAR). During review of R1’s PRN MAR (Acetaminophen, 500mg) LPA observed the “Date” column had the days portion redacted with whiteout. Deficiency cited.



During today’s visit, LPA observed two deficiencies faulting the facility.

An exit interview was conducted, and a copy of this report was reviewed and provided to Administrator Cerda along with an LIC809-D and Appeals Rights.

SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023
LIC809 (FAS) - (06/04)
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