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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800108
Report Date: 06/27/2022
Date Signed: 06/27/2022 01:46:34 PM


Document Has Been Signed on 06/27/2022 01:46 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:A B CARING SENIOR LIVING 2FACILITY NUMBER:
331800108
ADMINISTRATOR:CARRASCO, REBECCAFACILITY TYPE:
740
ADDRESS:470 MEADOWLARK LANETELEPHONE:
(951) 435-7592
CITY:PERRISSTATE: CAZIP CODE:
92570
CAPACITY:6CENSUS: 7DATE:
06/27/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Caretaker Sandy HendersonTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jesse Gardner and Licensing Program Manager (LPM) Joel Esquivel made an unannounced visit to follow up on a resident (R1) who was reported to be receiving care in relation to the ongoing investigation related to complaint #18-NP-20220620153849.

Upon arrival, LPA, and LPM met with Caregiver Sandy Henderson (S1) and explained the purpose of the visit, introduced themselves, and were granted access to the facility.

LPA and LPM conducted a tour of the facility and later interviewed R1, and S1. LPA found that there were 7 residents in the facility that has a clearance for a capacity of 6. Deficiency later cited.

During a tour of the facility, R1 was noted to have a black eye, and concluding an interview with R1, it was determined that they fell inside the facility at an undetermined time with no report sent to the Department, thus a deficiency was cited.

During a review of records, it was noted that R2 did not have an admission agreement, nor emergency contact information in their resident file. Thus a deficiency was issued.

Due to a zero tolerance for unapproved capacity increase, the facility would be assessed an immediate civil penalty in the amount of $500.

Continued on LIC809-C.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2022
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 4


Document Has Been Signed on 06/27/2022 01:46 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: A B CARING SENIOR LIVING 2
FACILITY NUMBER: 331800108

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/28/2022
Section Cited

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87158 Capacity (a) A license...shall be the maximum number of residents which can be provided care at any given time...This requirement was not being met as evidenced by:
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Based on LPA's record review, LPA determined that the facility had 7 residents in care in which the capacity exceeded a maximum of 6. Licensee did not ensure that placement was obtained prior to hitting the maximum capacity as set forth by the fire clearance. This poses an immediate health and safety, and personal rights risk to residents in care.
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Type B
07/11/2022
Section Cited

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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports..the following:(1) A written report shall be submitted to the licensing agency.. resident within seven days...
(B) Any serious injury..
This requirement was not being met as evidenced by:
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Based off of LPA's record review of reported incidents to the Department, LPA determined that the Licensee did not adhere to the regulation by reporting the incident. This poses a potential health and safety and personal rights 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: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 06/27/2022 01:46 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: A B CARING SENIOR LIVING 2
FACILITY NUMBER: 331800108

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/11/2022
Section Cited

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87506 Resident Records: (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
This requirement was not being met as evidenced by:
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Based on LPA's record review of resident files, LPA found missing admission agreements, emergency contact information for R2. Licensee did not ensure records were updated. This poses a potential health and safety risk and 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: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


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: A B CARING SENIOR LIVING 2
FACILITY NUMBER: 331800108
VISIT DATE: 06/27/2022
NARRATIVE
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Based on today's visit, deficiencies were observed in the areas evaluated and cited according to California Code of Regulations, Title 22, Division 6.

An exit interview was conducted with Ms. Henderson in which a copy of this report was discussed with and provided along with copies of the LIC811, LIC809-D(2), LIC421IM, and Appeal Rights.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2022
LIC809 (FAS) - (06/04)
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