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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800491
Report Date: 03/13/2024
Date Signed: 03/13/2024 01:15:21 PM


Document Has Been Signed on 03/13/2024 01:15 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:SAN JACINTO RESIDENTIAL CARE FACILITYFACILITY NUMBER:
331800491
ADMINISTRATOR:BELTRAN, NICCOLOFACILITY TYPE:
735
ADDRESS:245 E SIXTH STREETTELEPHONE:
(951) 654-8555
CITY:SAN JACINTOSTATE: CAZIP CODE:
92583
CAPACITY:60CENSUS: 21DATE:
03/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator, Bienvenido RosanaTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola conducted a required annual visit. LPA was greeted and was granted entry and met with Administrator, Bienvenido Rosana, who was informed of the purpose of the visit. At time of visit there were (4) staff present.

The facility is comprised of (3) one story buildings with resident bedrooms, bathrooms, activity room, and dining areas. The facility does not have a pool or fire arms. The facility serves adults ages 18 to 59. LPA conducted a tour of the interior and exterior and reviewed facility documents and conducted staff and resident interviews.

Infection Control: LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. The facility has a infection control plan on file. The facility did not have hand hygiene supplies in facility common restrooms, and had (1) soap bottle in stock. Deficiency was cited and plan of correction was created. Facility cleaners were also observed unlocked in the facility kitchen. Deficiency was cited and plan of correction was created. Physical Plant: Physical plant, floors, windows, and doors were observed. The facility restrooms were observed to be visibly soiled sinks and floors. Based on interviews it was also found that facility TV was broken. Deficiency as cited and plan of correction was created. Laundry equipment was observed to be in good working condition. The carbon monoxide detector was operational during the visit. Food Service: LPA observed facility kitchen had the ability to prepare food. LPA observed the facility met the required food items. Record Review and Resident/Staff Files: LPA reviewed staff files and training that contained staff criminal clearance and updated training along with CPR/First Aid. Client files were reviewed and possessed all required paperwork. Health Related Services/ Incidental Medical Services: All client medication was locked in file cabinet. Medication had required labeling and was accounted for. Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing last fire drill conducted on 1/15/2024.

Based on interview and observation, it was found that the facility is not conducting regular activities for the residents. Deficiency was cited and plan of correction was created. It was also found that the facility is not providing hygiene supplies to residents. Deficiency was cited and plan of correction was created.

An exit interview was conducted where a copy of this report, appeal rights and deficiency page were provided to Administrator, Rosalinda Orleans
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-233-6759
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2024
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 5


Document Has Been Signed on 03/13/2024 01:15 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: SAN JACINTO RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 331800491

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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 with facility restrooms which were unclean and did not have the appropriate hand hygiene supplies which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/14/2024
Plan of Correction
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The licensee agreed to send LPA proof of purchased hand soap, and agreed to provide this to facility residents. Administrtor also stated they would have the resident restrooms cleaned and show LPA proof of this by POC due date. Licensee also agreed to provide staffing plan for when housekeeping staff is off to ensure the facility is clean and sanitary.
Type B
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that 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 ith cleaning supplies which were foudn unlocked in the facility kitchen which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/14/2024
Plan of Correction
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LPA had staff secure the items during the time of the visit as the staff did not have a key to lock the supplies in the cabinet. The licensee agreed to obatin a lock for the cleaning supplies to ensure they are kept out of reach of the residents. Proof of this is due by the POC due date.
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: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-233-6759
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 03/13/2024 01:15 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: SAN JACINTO RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 331800491

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(g)
(g) The licensee shall provide and maintain the equipment and supplies necessary to meet the requirements of the planned activity program.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview and record review, the licensee did not comply with the section cited above will broken TV in the activity room and incomplete games for residents which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2024
Plan of Correction
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The licensee agreed to have the TV fixed in the activity room and agreed to send a written plan on who will conduct activities on activity calendar.
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: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-233-6759
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5