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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800108
Report Date: 07/11/2022
Date Signed: 07/11/2022 12:04:17 PM


Document Has Been Signed on 07/11/2022 12:04 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: 6DATE:
07/11/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Rebecca Carrasco, LicenseeTIME COMPLETED:
12:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Chinwe Nwogene arrived unannounced to the facility to conduct a case management visit regarding facility being over capacity and to notify Licensee the eviction notice received by CDSS, does not meet regulatory requirement. LPA met with Caregiver, Lucinda Henderson and explained the purpose of the visit. Lucinda called Licensee, Rebecca Carrasco who arrived at the facility shortly after.

LPA toured the facility inside and out. LPA observed 6 (six) out of 7 (seven) residents in care. Rebecca stated that resident #7 (R7) has not returned to the facility but R7 property is still in the facility. Rebecca stated that facility is in contact with a referral agency and has faxed all the required document they need to place R7 in another facility. Rebecca stated that facility does not know yet, the facility R7 will be placed in.

LPA informed Licensee that R7 eviction notice received from the facility on 7/8/2022 does not meet regulatory requirement. LPA advised Licensee what corrections are needed. Licensee agreed to email an updated eviction notice by 7/12/2022.

Also during the tour, LPA observer unlocked cleaning detergents/solutions on top of a washing machine in an unlocked laundry room. Citation will be issued.

Based on today's visit, deficiency was observed in the area evaluated and cited according to California Code of Regulations, Title 22, Division 6.

An exit interview was conducted with Rebecca Carrasco in which a copy of this report was discussed with and provided along with copies of the LIC811, and Appeal Rights.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Chinwe NwogeneTELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2022
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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Document Has Been Signed on 07/11/2022 12:04 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: 07/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/21/2022
Section Cited

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Any item which could pose a danger to resident, including cleaning solutions, poisons, and other items, shall be made inaccessible to residents.
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Based on LPA's observation, Licensee failed to comply with the section cited above which poses an immediate health and safety risk to persons 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: Chinwe NwogeneTELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2022
LIC809 (FAS) - (06/04)
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