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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800112
Report Date: 08/14/2024
Date Signed: 08/14/2024 05:08:16 PM


Document Has Been Signed on 08/14/2024 05:08 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:EMANUEL HOME CAREFACILITY NUMBER:
331800112
ADMINISTRATOR:POPA, LIDIA DFACILITY TYPE:
740
ADDRESS:10820 CALLE BELLATELEPHONE:
(951) 772-0209
CITY:RIVERSIDESTATE: CAZIP CODE:
92503
CAPACITY:6CENSUS: 2DATE:
08/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:52 PM
MET WITH:Jac Anda, StaffTIME COMPLETED:
05:20 PM
NARRATIVE
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Licensing Program Analyst (LPA), Stephanie Martinez, conducted a required annual inspection at the facility. The LPA was allowed entrance into the facility and met with staff, Jac Anda. The Administrator, Lidia Popa, was notified of the purpose for the visit via telephone. The inspection included the following:

Physical Plant: The facility consists of four (4) resident bedrooms, four (4) staff/private rooms, three (3) bathrooms, storage areas, a kitchen and dinning areas, one (1) living space, two laundry rooms, and a patio and yard with sufficient seating and space for activities. There are no bodies of water located on the property. According to staff Anda, no weapons are stored in the home. The facility is being maintained at a comfortable temperature. All outdoor and indoor passageways are kept free of obstruction and are free of debris and other trash. There are grab bars for each toilet, bathtub and shower used by residents. The smoke and carbon monoxide devices were tested by staff Anda and were observed to be in operating condition. The home was kept clean and organized. LPA was notified by staff there is no facility telephone at this time, after the LPA was unable to reach the facility at the number listed, on 08/14/2024. On 08/11/2023 the facility was also unable to be contacted by LPA, Sara Martinez, during a visit. A citation will be issued.

Food Service: There is a minimum of 2 days supply of perishable foods and 1 week's supply of non-perishable foods available. Sufficient dinning supplies were available for residents in care. A variety of food was available and stored in a safe and healthful manner.

Record Review: All staff were observed to have appropriate fingerprint clearances. LPA did not observe any excluded individuals on the premises at time of visit. Staff responsible for direct care and supervision have current first aid and CPR training. Completed training included dementia related training, hospice related training, postural support related training, and emergency training. The facility currently has an approved Hospice Waiver for two (2) residents and there is currently one resident in care receiving hospice services. Proof of emergency drills were observed on file. All records were observed to be well organized. LPA
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024
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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: EMANUEL HOME CARE
FACILITY NUMBER: 331800112
VISIT DATE: 08/14/2024
NARRATIVE
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observed during a review of resident records there is a bedridden resident in care, Resident Two (R2). The Physician's Report for Residential Care Facilities for the Elderly (RCFE) indicated the resident is bedridden. According to Administrator Popa, R2 is not bedridden; however, one staff interview reported R2 is unable to rotate on their own. A citation will be issued and civil penalty will be issued. A review of the hospice file for Resident Two (R2) was completed. No hospice care plan was observed on file. A citation will be issued. The LPA reviewed the facility's liability insurance. The liability insurance on file indicated the general aggregate is $2,000,000.00 rather than a total annual aggregate of $3,000,000.00. A citation will be issued.

Medication Review: The LPA inspected resident medications. Medications were observed to be well organized, appropriately labeled and inaccessible to unauthorized individuals.

An exit interview was conducted with Administrator Popa, in which this report was discussed and a copy was provided, along with the LIC 811, LIC 9098, and instructions on appeal rights. This report was also reviewed with staff Anda.

SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 08/14/2024 05:08 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: EMANUEL HOME CARE
FACILITY NUMBER: 331800112

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(2)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons

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 in [1] out of [1] residents in care who are bedridden. The facility does not have a bedridden fire clearance. This poses an immediate health, safety and personal rights risk to persons in care.
POC Due Date: 08/15/2024
Plan of Correction
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Administrator stated she would get clarification from the hospice agency related to R2's ambulatory status. Administrator stated she understood the resident would have to be moved within 24 hours if a bedridden status is confirmed for the resident.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Rikesha StampsTELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 08/14/2024 05:08 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: EMANUEL HOME CARE
FACILITY NUMBER: 331800112

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above due to the liability insurance on file indicating the general aggregate is $2,000,000.00 rather than a total annual aggregate of $3,000,000.00. This poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 08/20/2024
Plan of Correction
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 Administrator stated the Liability Insurance would be updated and a copy would be submitted to the Department by the POC due date.
Type B
Section Cited
CCR
87311
Telephones
All facilities shall have telephone service on the premises. Facilities with a capacity of sixteen (16) or more persons shall be listed in the telephone directory under the name of the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in [2] out of [2] instances in which the facility was attempted to be contacted; however, the telephone was not in working order. On 08/11/2023 the facility was unable to be contacted by LPA, Sara Martinez, and on 08/14/2024, the facility was unable to be contacted by LPA, Stephanie Martinez. This poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 08/21/2024
Plan of Correction
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Administrator stated the facility telephone number will be updated and a written notification letter will be submitted to the Department by the 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: Rikesha StampsTELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 08/14/2024 05:08 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: EMANUEL HOME CARE
FACILITY NUMBER: 331800112

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87633(b)
Hospice Care for Terminally Ill Residents
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following:

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 [1] out of [1] residents who did not have a current or complete hospice care plan on file. This which poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 08/23/2024
Plan of Correction
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The Administrator stated a copy of the hospice care plan will be obtained and a copy submitted to the Department by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Rikesha StampsTELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5