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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800081
Report Date: 10/25/2022
Date Signed: 10/25/2022 12:20:58 PM


Document Has Been Signed on 10/25/2022 12:20 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:BUSMAN RESIDENTIAL CARE LLCFACILITY NUMBER:
331800081
ADMINISTRATOR:READE, JOHNFACILITY TYPE:
740
ADDRESS:27892 BUSMAN ROADTELEPHONE:
(951) 888-9512
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY:6CENSUS: 6DATE:
10/25/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Administrator John ReadeTIME COMPLETED:
12:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola made an unannounced visit in order to conduct a health and safety check. LPA met with administrator John Reade, who was informed of the purpose of the visit. At the time of the visit there were (2) staff and (5) residents present.

LPA proceed to conduct a walk through of the facility. LPA observed that the home was being painted from the outside, and did not observed any active construction in the interior of the home. LPA spoke with administrator who confirmed this, and stated that the home would be painted for the next (3) days. LPA was informed (1) resident was at the hospital during the visit whom had a doctor's appointment. LPA proceeded to observe the facility medications cart and the central entry point. LPA had her temperature taken upon arrival to the facility. LPA walked through the resident rooms and observed the (5) resident, (3) were in the upstairs family room watching tv and reading magazines. (1) resident was seated at the dining table, and (1) resident was in their room.

LPA requested staff file for the administrator and the administrator was unable to provide it at the time of the visit. This will be documented on deficiency page along with the plan of correction. LPA requested resident files, which administrator was unable to provide at the time of the visit. This deficiency will be documented along with the plan of correction. LPA requested the most up to date copy of the LIC500 and LIC9020. Administrator stated that he had these documents but was unable to access it as it was in the facility garage and could not be accessed in a timely manner . This deficiency will be documented along with plan of correction.

An exit interview was conducted where a copy of this report along with LIC 809-D pages and appeal rights were reviewed and provided to administrator, John Reade.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2022
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 10/25/2022 12:20 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: BUSMAN RESIDENTIAL CARE LLC
FACILITY NUMBER: 331800081

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/04/2022
Section Cited

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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 requirment was not met as evidenced by:
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Based on interview LPA was informed by administrator that the documentation for staff and himself where in the fcaility garage and he would not be able to access it in a timely manner. Therefore, LPA was unable to review and collect documentation at the time of the visit. This poses a potential health, saftey, or personal rights risk for residents in care.
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Type B
11/04/2022
Section Cited

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87506 Resident Records (d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours...
This requiremnt was not met as evidenced by:
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Based on interview with administrator, the resident files were unable to be provided in a timely manner. Therefore, the LPA was unable to review these documents during the time of the visit. This poses a potential heath, saftey, or personal rights risk to residents in care.
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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: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 10/25/2022 12:20 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: BUSMAN RESIDENTIAL CARE LLC
FACILITY NUMBER: 331800081

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/04/2022
Section Cited

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87508 Register of Residents (b) Registers of residents shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours...
This requirment was not met as evidenced by:
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Based on interview with administrator who stated the register was located in the facility garage and could not be accessed in a timely manner. This poses a potential health, saftey, or personal rights risk to residents in care.
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Type B
11/04/2022
Section Cited

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87412 Personnel Records (e) In all cases, personnel records shall demonstrate adequate staff coverage necessary for facility operation by documenting the hours actually worked.
This requirment was not met as evidenced by:
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Based on interview with administrator, LPA was informed that the staff scheduleLIC500 could not be accessed in a timely manner as this document was amoung others in facility file boxes in the facility garage. This poses a potential health, saftey, or persinal rights risk for residents in care.
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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: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3