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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800112
Report Date: 08/11/2023
Date Signed: 08/11/2023 05:59:19 PM


Document Has Been Signed on 08/11/2023 05:59 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 AC/SC, 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: 4DATE:
08/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Anda Jac - CaregiverTIME COMPLETED:
06:13 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit. LPA was granted entry and met with Caregiver, Anda Jac, who was informed of the purpose of the visit. At the time of the visit there was (1) staff and four (4) residents present.

The facility is a two story home with seven (7) bedrooms and (3) bathrooms with attached garage (four (4) bedrooms and two (2) bathrooms upstairs are designated for the live in licensee/family). The clients served are elderly adults 65 years 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 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. LPA observed chemicals and cleaning solutions under the kitchen's sink cabinet unlocked and accessible to the residents. LPA observed chemicals and laundry detergent in the unlocked garage accessible to the residents. This requirement does not meet Title 22 regulations and LPA will issue a deficiency along with a plan of correction. The smoke detector and carbon monoxide was operational, and the hot water temperature 115.7 F.

Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed containers of expired milk, orange juice, and a carbonated drink in the refrigerator. The food/beverages was not kept in good quality that meets Title 22 Regulations. A deficiency will be issued along with a plan of correction. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2023
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 6


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: EMANUEL HOME CARE
FACILITY NUMBER: 331800112
VISIT DATE: 08/11/2023
NARRATIVE
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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 three (3) staff files and training. LPA observed Staff One (S1) was not associated to the facility. A civil penalty will be issued. LPA observed S1 did not have a current CPR/First Aid Certificate on file which does not meet Title 22 Regulations and a deficiency along with a plan of correction will be issued. Four (4) resident files were reviewed and possessed all required paperwork.



Health Related Services/ Incidental Medical Services: All client medication was locked in the garage in a cabinet. LPA reviewed resident medications for four (4) residents and found that discrepancies between the MARS issued to the residents and the medication the facility had for Resident One (R1) and Resident Two (R2). Facility does not document daily dispensing of medication to the residents and S1 stated they only go by what is written on the bottles/bubble pack. For R1, SIMVASTATIN 10 MG is supposed to be given to R1 in the evening per Physician's orders but on the bubble pack the facility wrote in "AM". The bubble pack for SIMVASTATIN was issued on 08/01/2023 and had the 11th date popped out and dispensed. LPA observed facility was giving R1 PRN medication ACETAMINOPHEN without documenting the date, time, and dosage that was given which does not meet Title 22 regulations and a deficiency will be issued along with a plan of correction. LPA observed 9 medications for R2 that was on the Physician's order was not at the facility. LPA inquired about it to the Administrator and she stated she was not sure where the medication was due to the resident recently returned from the hospital today 08/11/2023.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation in the facility's Emergency and Disaster plan that showed they have not conducted a fire drill within the year and their Fire/Earthquake drill form was from 2018, which does not meet the department requirements. A deficiency will be issued along with a plan of correction. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies in the garage and first aid kit with all required items.

An exit interview was conducted where a copy of this report, deficiency page LIC809D, Civil Penalties, and appeal rights was provided to caregiver, Anda Yac.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 08/11/2023 05:59 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 AC/SC, 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: 08/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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
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Based on observation and interview, the licensee did not comply with the section cited above in keeping the cleaning solutions and disinfectants under the kitchen sink cabinet and garage inaccessible to the residents as the cabinet was unlocked and garage unlocked which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/18/2023
Plan of Correction
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Licensee will read and understand Title 22 regulations regarding keeping disinfectants, cleaning solutions, and poisons inaccessible and locked and provide staff training. Licensee will submit proof of staff training was conducted and a statement of acknowledgment to LPA by the due date 08/18/2023.
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in having Staff One (S1) who was working at the facility alone have a current CPR/First aid certificate at the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/18/2023
Plan of Correction
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Licensee will submit proof Staff One (S1) has taken and received a CPR/First Aid Certificate by the due date 08/18/2023.
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) 248-0312
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2023
LIC809 (FAS) - (06/04)
Page: 3 of 6


Document Has Been Signed on 08/11/2023 05:59 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 AC/SC, 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: 08/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having expired milk, orange juice and a corbinated drink in the facility's refrigerator which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/18/2023
Plan of Correction
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Licensee will dispose of the expired product and submit a statement of understanding of the regultion cited above to LPA by the agreed due date 08/18/2023.
Type B
Section Cited
CCR
87465(h)(4)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above for R1 and their medication SIMVASTATIN 10 MG is supposed to be given to R1 in the evening per Physician's orders but on the bubble pack the facility wrote "AM". The bubble pack for SIMVASTATIN was issued on 08/01/2023 and had the 11th date popped out and dispensed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/18/2023
Plan of Correction
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Licensee will submit a statement to LPA with an understanding of the section cited above and provide staff training so the staff can properly follow the physician's orders when dispensing medication to the residents. Licensee will submit proof of staff training was conducted and a statement of acknowledgment to LPA by the due date 08/18/2023.
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) 248-0312
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2023
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 08/11/2023 05:59 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 AC/SC, 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: 08/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(d)(3)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in facility giving Resident One (R1) PRN medication ACETAMINOPHEN without documenting the date, time, and dosage that was given which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/18/2023
Plan of Correction
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Licensee will provide a statement of understanding for the section cited above and will provide staff training on how to properly dispense medication to the residents and document when PRN was given. Licensee will submit proof of staff training was conducted and a statement of acknowledgment to LPA by the due date 08/18/2023.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in conducting quarterly fire and earthquake drills which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/18/2023
Plan of Correction
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Licensee will conduct a fire and earthquake drill and send proof to LPA by the due date 08/18/2023
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) 248-0312
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2023
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 08/11/2023 05:59 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 AC/SC, 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: 08/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87355(e)(2)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in having Staff One (S1) associated to work at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/18/2023
Plan of Correction
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Licensee will associate S1's criminal background clearance to the facility and submit proof to LPA by POC due date 08/18/2023.
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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2023
LIC809 (FAS) - (06/04)
Page: 6 of 6