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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800491
Report Date: 12/16/2022
Date Signed: 12/16/2022 04:10:08 PM


Document Has Been Signed on 12/16/2022 04:10 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: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: 49DATE:
12/16/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Administrator, Arnel VirayTIME COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced visit to the facility in order to follow up on an incident that happened at the facility. LPA met with Administrator, Arnel Viray who was informed of the purpose of the visit.

The department received an incident report on 12/15/2022 for an incident that occurred with resident 1 (R1) on 12/12/2022. LPA spoke with Administrator to obtain a timeline of events, and collected admissions agreement, care plan, and physicians report and incident reports for R1. LPA found that on 12/12/2022 R1 called 911 while in the facility dining area, this was observed by Administrator. R1 then went into the front yard of the facility, and during the time it took paramedics to arrive, R1 had cut themselves with a piece of glass. Paramedics treated R1's wounds. Administrator stated they did not witness R1 cut themselves, R1 was not monitored in the front yard, and R1 was not checked for injuries or dangerous objects after calling 911. LPA reviewed facility documents that corroborated the Administrator's statements of R1 having a history of cutting themselves. Incident report for 3/2/2022, 3/23/2022, 6/3/2022, and 11/7/2022 detailed similar attempts of R1 cutting themselves with pieces of glass. There is currently no plan documented to monitor resident's behavior concerning this.

As a result of the visit, the Administrator has stated they will personally monitor the resident four (4) times a day for changes in mental condition. The staff will also monitor R1's phone calls to ensure staff is aware when R1 has called 911. Staff will subsequently check R1's person for any objects that can pose a danger to R1's safety and monitor R1 until paramedics arrive. Upon the administrator's absence, Administrator will designate Staff 1 (S1) to carry out this plan and ensure the resident has proper supervision. Going forward the Administrator will ensure that the resident is re-evaluated to ensure the facility is the correct fit for R1. The care plan will be updated to reflect these points. Administrator will provide written plan 12/23/2022, and statement that re-evaluation has been scheduled.

LPA conducted a health and safety check of the facility. LPA conducted a walk through of the facility, observed residents in care and did not observe any immediate health and safety risks to residents in care. R1 was observed to be back at the facility in their room.

An exit interview was conducted where this report was reviewed and provided to, Administrator Arnel Viray.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2022
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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