331800097-6-22-2023-18-AS-SMAZ-CT2PL2-20230622112400

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331800097
Report Date: 06/22/2023
Date Signed: 06/22/2023 11:24:19 AM

Document Has Been Signed on 06/22/2023 11:24 AM - 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:	CENTER PLAZA SENIOR LIVING LLC		FACILITY NUMBER:	331800097
ADMINISTRATOR:	MERCEDES DEMONTEVERDE		FACILITY TYPE:	740
ADDRESS:	3171 CENTER STREET		TELEPHONE:	(951) 213-2283
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92501
CAPACITY:	6	CENSUS: 5	DATE:	06/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Christina Balaguer		TIME COMPLETED:	11:40 AM

NARRATIVE

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Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit. LPA was granted entry and met with Administrator, Christina Balaguer, who was informed of the purpose of the visit. At the time of the visit there was (2) staff and (5) resident's present.

The facility is a one-story home with (6) bedrooms and (2) bathrooms and a locked shed with three doors in the backyard. The clients served are elderly adults 65 years of age and older. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted a staff and client interviews. LPA observed the following:

Infection Control: The LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements. LPA reviewed staff records and found that all staff had infection control training.

Physical Plant: LPA observed the client bedrooms and staff office. Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards.LPA observed outdoor furniture and shaded area for clients. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to clients. Kitchen cabinet under the sink that stored chemicals was unlocked. A deficiency will be cited along with a plan of correction. The smoke detector and carbon monoxide was operational, and the hot water temperature 119F.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Sara Martinez	TELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CENTER PLAZA SENIOR LIVING LLC	FACILITY NUMBER: 331800097
	VISIT DATE: 06/22/2023

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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.

Care & Supervision/Administration: Adequate staff are present for the supervision of clients during the visit. LPA also reviewed the staff scheduled showing adequate staff coverage. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The listed administrator possesses a current administrator's certificate.

Record Review and Resident/Staff Files: LPA reviewed (2) staff files and training. All staff have criminal clearance and updated training along with CPR/First Aid Certification. Four (4) resident files were reviewed and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: All resident medication was locked in a cabinet in the kitchen. LPA reviewed medications for (2) residents and found incomplete log of MARS. MARS was observed to not have had administration date signature since 06/18/2023. A deficiency will be issued as well as a plan of correction. Medication listed on MARS had all required labeling and was found to be accurate and in place.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing the facility's last fire and earthquake drills, which met the department requirements. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies and first aid kit with all required items.

An exit interview was conducted where a copy of this report along with deficiency page and appeal rights were reviewed and provided to the Administrator, Christina Balaguer.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Sara Martinez	TELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/22/2023 11:24 AM - 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: CENTER PLAZA SENIOR LIVING LLC	FACILITY NUMBER: 331800097
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in keeping the chemicals and cleaning solutions under the kitchen sink locked and inaccessible to the residents in care which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/23/2023
	Plan of Correction
1 2 3 4	The licensee shall ensure that chemicals will be locked at all times and a statement will be given to LPA that staff have been trained and understand all cleaning supplies are kept inaccessible when not in use. Proof will be submitted to the Department by the agreed POC due date.

Type A

Section Cited

CCR

87465(a)(5)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in recording the dates of medication administration in the MARS log for residents since 06/18/2023 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/23/2023
	Plan of Correction
1 2 3 4	The Licensee shall ensure medication will be logged daily by the administer and will provide a statement as proof of staff training on Title 22 regulations on proper medication procedures. Proof will be submitted by the Department by the agreed 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 Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Sara Martinez	TELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

LIC809 (FAS) - (06/04)

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