331800126-3-14-2022-18-AS-DCUS-CCHRS4-20220314131607

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331800126
Report Date: 03/14/2022
Date Signed: 03/14/2022 01:16:16 PM

Document Has Been Signed on 03/14/2022 01:16 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:	NUEVO RANCH RESIDENTIAL FACILITY		FACILITY NUMBER:	331800126
ADMINISTRATOR:	WALKER, ADRIENNE		FACILITY TYPE:	735
ADDRESS:	27031 NUEVO ROAD		TELEPHONE:	(951) 796-7623
CITY:	PERRIS	STATE: CA	ZIP CODE:	92571
CAPACITY: 5		CENSUS: 2	DATE:	03/14/2022
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Caregiver, Talaysia Dickson		TIME COMPLETED:	01:20 PM

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Licensing Program Analyst (LPA), David Cuevas conducted an unannounced Case Management visit to facility regarding a death report received at regional office on 03/11/2022. LPA met with direct support staff, Talaysia who proceeded to call Licensee, Adrienne Walker who made herself available via telephone.

During case management visit LPA interviewed staff #1(S1) and reviewed residents #1 (R1)’s file.

Per interviews and available records resident passed away on 01/30/2022 at the Hospital in their Intensive Care Unit (ICU). Cause of death is unknown at this time, per S1, R1’s family were the ones receiving updates from hospital staff and failed to communicate cause of death to facility. Per S1, prior to death R1 went into the Emergency Room (ER) on 11/25/2021 for not being able to breath and stayed at the hospital until date of death on 01/30/2022 During visit LPA requested the following documents:

· Admission Agreement

· Needs and Service Plan

· Psychiatric Evaluation and Medical Notes/Orders

· Unusual Incident Reports

· Resident Daily Notes

· ID/ Emergency Information

· Physicians Report

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: David Cuevas
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2022

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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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: NUEVO RANCH RESIDENTIAL FACILITY	FACILITY NUMBER: 331800126
	VISIT DATE: 03/14/2022

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· Medication Administration Records (MAR)

· Personal Property Record

· Weight Record

· Laboratory Paperwork.

A death report has not been submitted yet. However, per Licensee a death report will be submitted by tomorrow 03/15/22, by 5:00pm. Additionally, per Licensee, a death certificate will be requested and provided to CCL, when available.

Due to facility not reporting R1’s death on a timely manner deficiency will be cited on LIC 809 D.

An exit interview was conducted, were this report, LIC 811, LIC 809 D, and appeal rights were reviewed and provided to facility representative Talaysia.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: David Cuevas
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/14/2022 01:16 PM - It Cannot Be Edited

Created By: David Cuevas On 03/14/2022 at 12:43 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: NUEVO RANCH RESIDENTIAL FACILITY	FACILITY NUMBER: 331800126
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/14/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type B 03/18/2022 Section Cited CCR 80061(a)(b)(1)(A)	1 2 3 4 5 6 7	Reporting Requirement (a) Licensee shall furnish to the licensing agency…A report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information…shall be submitted to the licensing agency within seven days following…the death of any client from any cause. This requirement was not met evidence by:	1 2 3 4 5 6 7	Licensee will provided a statement of understanding, identifying the facilities understanding of reporting requirements and responsibility of reporting a residents death per cited regulation. Plan of correction due by 3/18/22.
	8 9 10 11 12 13 14	Facility failed to inform CCL of R1's death occurring on 1/29/22. No death report or SIR provided as of 3/14/22, this possess a risk to the safety, health, and personal rights of resident 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:

Jazmond D Harris

LICENSING EVALUATOR NAME:

David Cuevas

LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2022

LIC809 (FAS) - (06/04)

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