<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800114
Report Date: 11/06/2023
Date Signed: 11/06/2023 03:45:39 PM


Document Has Been Signed on 11/06/2023 03:45 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:VINEYARD RANCH AT TEMECULAFACILITY NUMBER:
331800114
ADMINISTRATOR:KURT KNAUERFACILITY TYPE:
740
ADDRESS:27350 NICOLAS RDTELEPHONE:
(951) 308-1988
CITY:TEMECULASTATE: CAZIP CODE:
92591
CAPACITY:0CENSUS: 95DATE:
11/06/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Business Office Manager Jonah VillegasTIME COMPLETED:
03:56 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst Jesse Gardner conducted an unannounced case management visit. LPA met with Business Office Manager Jonah Villegas During the investigation of Complaint Control # 18-AS-20200601103146 staff stated they administered Resident 1’s (R1) Tylenol medication by crushing it and placing it in R1’s food. Based on a review of R1’s resident file, there was not an order by the Physician instructing the medication be crushed when administering it to R1.

Based upon the information obtained and in accordance with Title 22 Regulations, Section 6, a citation is being issued on the attached LIC809D. An exit interview was conducted and a copy of this report, along with LIC811 (Confidential Names List) and Appeal Rights was reviewed with and provided to Ms. Villegas.

SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:
DATE: 11/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2023
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 2


Document Has Been Signed on 11/06/2023 03:45 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: VINEYARD RANCH AT TEMECULA
FACILITY NUMBER: 331800114

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/20/2023
Section Cited
CCR
87465(c)(2)

1
2
3
4
5
6
7
Incidental Medical and Dental Care: If the resident's physician has stated in writing
that the resident is unable to determine his/her own need for nonprescription PRN medication
but can 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:
1
2
3
4
5
6
7
Licensee agrees to conduct in-service training with all staff regarding following physician orders, and the cited regulation. Licensee agrees to provide proof of such to LPA by POC date.
8
9
10
11
12
13
14
(2)Once ordered by the physician the medication is given according to the
physician's directions. This requirement was not being met as evidenced by: Facility staff stated they
could crush R1’s Tylenol medication and put it applesauce when administering it to him. R1 did not have
doctor’s instructing facility staff to crush the medication for R1. This is a potential health and safety risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:
DATE: 11/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2