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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800173
Report Date: 02/20/2024
Date Signed: 02/20/2024 10:09:51 AM


Document Has Been Signed on 02/20/2024 10:09 AM - 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:MEGGINSON PLACE IIFACILITY NUMBER:
331800173
ADMINISTRATOR:RACELIS, JANETTEFACILITY TYPE:
740
ADDRESS:11330 LOMBARDY LANETELEPHONE:
(951) 363-8767
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY:6CENSUS: 5DATE:
02/20/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Janette Racelis, Licensee/AdministratorTIME COMPLETED:
10:15 AM
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On today's date 02/20/24, Licensing Program Analyst (LPA) Javina George conducted an unannounced Health and Safety check at the facility. LPA was greeted and granted entry by Licensee Janette Racelis, and explained the purpose of the visit. At the time of LPAs visit there were two (2) staff and five (5) resident's present. Both staff were observed to have obtained criminal record clearance and were associated to the facility. There were three (3) resident's sleeping, two (2) resident's watching a television program.

The facility has an approved hospice waiver for four (4) residents. The facility continues to have three (3) residents that are under hospice care. All resident's on hospice have a DNR as indicated on their Physician's Orders for Life Sustaining Treatment (POLST). There is one bedridden resident (resident #1/R1), whom resides in bedroom #3.

LPA conducted a tour of the interior and exterior of the facility. The facility has five (5) residents bedrooms and (2) staff bedrooms and 4 bathrooms. There is currently one vacant resident bedroom. LPA observed for the facility to have the required postings such as personal rights, Emergency disaster plan (LIC610E), facility License, Long Term Ombudsman Poster (LTCO) poster and department complaint poster (PUB 475). In regards to the uneven pavement at the end of the driveway, the repair is scheduled to begin on 3/19/24 and expected to be completed on 3/20/24.

Regarding the use of video surveillance. As discussed on 2/2/24, the licensee, Mrs. Racelis submitted an addendum to the facility's plan of operation, obtained signed consents from all five (5) of the residents and or their responsible parties, as well as provided an updated facility sketch indicating where the camera's are placed throughout the facility. A copy is on file at the regional office.

The facility was observed to have operable utilities (electric, water, gas). LPA observed for the facility food supply to meet with minimum requirements of a 2 day supply of perishable and 7 day supply of
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2024
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: MEGGINSON PLACE II
FACILITY NUMBER: 331800173
VISIT DATE: 02/20/2024
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nonperishable food items. The facility was observed to have at minimum of a 30 day supply of Personal Protective Equipment (PPE). LPA observed for the facility to have paper supplies (paper towels, toilet paper) and EPA approved cleaners.

The facility has an abundance of hygiene supplies available for residents in care to use. The resident's medications were observed to be locked and inaccessible to the resident's in care.

No health and safety concerns were observed during today's visit.

An exit interview was conducted, and a copy of this report, and LIC 811 was discussed and provided to Licensee Janette Racelis.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2024
LIC809 (FAS) - (06/04)
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