331800444-4-25-2023-18-AS-JGEE-CR8QY5-20230425123434

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331800444
Report Date: 04/25/2023
Date Signed: 04/25/2023 12:34:41 PM

Document Has Been Signed on 04/25/2023 12:34 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:	VIDA HOME SERVICES INC		FACILITY NUMBER:	331800444
ADMINISTRATOR:	BESINA JR, AURELIO		FACILITY TYPE:	735
ADDRESS:	983 SAW TOOTH LANE		TELEPHONE:	(562) 569-8115
CITY:	HEMET	STATE: CA	ZIP CODE:	92545
CAPACITY:	5	CENSUS: 3	DATE:	04/25/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Edwin Nunez, Caregiver		TIME COMPLETED:	12:50 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 (LPA) Javina George conducted an unannounced annual/1 year required visit on April 25, 2023 at 10:00am. LPA was granted entry by Caregiver Edwin Nunez, who was informed of the purpose of the visit. The Administrator Cheryl Balquiedra was not able to come to the facility, but was available via telephone.

The facility is a single story home with (4) bedrooms and (1) bathroom designated for the clients to use and there is one (1) bedroom fr or staff and one (1) bathroom available for both the clients and staff to use. During LPAs visit, LPA conducted a tour of the interior and exterior of the facility and observed the following:

Infection Control: LPA observed for the facility to have Personal Protection Equipment (PPE) supplies, and covid postings such as donning and doffing PPE proper hand washing to help minimize the spread of germs. The facility does not have an approved mitigation plan (LIC808) on file, Per the Administrator Ms. Cheryl Balquiera it was not completed as there were not any clients in care during the declared state of emergency. The Administrator agrees to submit the mitigation plan to the department by 5pm Friday 4/28/2023. If not received, than a deficiency will be cited.

Physical Plant: LPA observed the clients bedrooms which contained the required furniture. The interior and the exterior were observed to be clean, odor and clutter free. The floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair. The facility does not have a pool or any other bodies of water on the premises. The water temperature was tested and was found to be within regulatory limits 105.6-110.8 degrees Fahrenheit.

Food Service: LPA observed the kitchen to be clean and possess equipment in good working condition. LPA observed the facility had the required 2-day perishable and 7-day non-perishable food supplies. The sharp and dangerous objects are kept locked in a drawer of the island in the middle of the kitchen.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023

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 3

Document Has Been Signed on 04/25/2023 12:34 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: VIDA HOME SERVICES INC	FACILITY NUMBER: 331800444
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1565(d)

Other Provisions

(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee, administrator, or regulated individual shall sign and date the documentation to indicate that the plan has been reviewed and updated as necessary. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in one out of times, as the LIC610D has not been updated since October, 10, 2017, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/26/2023
	Plan of Correction
1 2 3 4	The Licensee agrees to complete an updated LIC 610D. Proof is to be submitted to the department by 5pm on the due date indicated.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: VIDA HOME SERVICES INC	FACILITY NUMBER: 331800444
	VISIT DATE: 04/25/2023

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
26
27
28
29
30
31
32

Care & Supervision/Administration: Adequate staff are present for the supervision of Clients. At the time of LPA's visit there was one (1) observed caregiver for the three (3) clients in care. Emergency exiting plans, emergency telephone numbers and personal rights were found posted in the facility on the wall inside the common area.

Record Review and Resident/Staff Files: LPA observed staff had current CPR/First Aid Certification. The (2) client files reviewed were also found to be completed with the required medical assessment, and appraisals, and other assessment such as the Individual Program Plan (IPP). Additionally, LPA conducted (1) staff interview. The staff was able to answer the questions without hesitation or clarification needed. LPA was unable to conduct client interviews, as the clients were at the day program at the time of LPAs visit.

Incidental Medical: LPA reviewed the medications for (2) clients and found that all clients medications were accounted for, with proper labeling, and medication administration log was found to be accurate and up to date.

Disaster Preparedness: The facility has record of conducted emergency drills (earthquake, fire). Per Caregiver Edwin , the drills are conducted on a monthly basis and the last drill fire and earthquake was on 3/13/23. The facility's fire alarms (4) and(1) carbon monoxide detectors were tested and are operable. LPA observed there to be two fire extinguishers on the premises located in the dining area, and the other located in the hallway by staff bedroom. LPA observed for the facility's Emergency disaster plan to not have been updated since 10/12/2017. Deficiency cited, as this poses an immediate health, safety and personal rights risk to persons in care.

An exit interview was conducted, where a copy of this report, 809C, 809D and appeal rights were reviewed and provided to Caregiver Edwin Nunez.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3