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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880494
Report Date: 07/16/2021
Date Signed: 07/16/2021 02:38:03 PM

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:TRUE FAMILY CAREFACILITY NUMBER:
331880494
ADMINISTRATOR:LUCENA, IANFACILITY TYPE:
740
ADDRESS:10225 BONITA AVETELEPHONE:
(951) 333-8649
CITY:RIVERSIDESTATE: CAZIP CODE:
92503
CAPACITY:6CENSUS: 6DATE:
07/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Claudia LucenaTIME COMPLETED:
02:47 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Le conducted an unannounced visit to the facility for an annual inspection. LPA initially met with caregiver Evelyn Eduardo. The administrator Claudia Lucena arrived during the visit.

LPA toured the facility inside and out. The facility has no bodies of water. The facility has charged fire extinguishers, operating smoke alarms, and carbon monoxide detectors. Outdoor and indoor passageways were kept free of obstruction. Cleaning supplies and sharps were kept in a safe and locked place. Cleaning supplies were stored underneath the kitchen sink and in the laundry room. Sharps were stored in a secured area. The facility had a complete first aid kit. LPA observed two (2) day supply of perishable food items and seven (7) day supply of nonperishable food items. The facility menu was available for review. The resident bedrooms had the required furniture and functional lighting. The facility had a supply of additional linen and extra hygiene items for the residents. LPA toured the resident bathrooms. LPA observed grab bars and non-skid mats. LPA measured the hot water temperature in the bathrooms. The hot water temperature measured at 105 degrees F.

LPA observed that the facility has a mitigation plan to mitigate the spread of COVID-19 in the facility. One central entry point and sign-in policy has been designated for universal entry screening. Routine symptom screening has been initiated at entry for all staff, residents, and visitors. Facility also documents daily temperature and COVID-19 symptom checks, and any change in condition for staff and residents. LPA observed hand sanitizer throughout the facility and a 30 day supply of PPE. All residents have at least a 30 day supply of medications. LPA observed that all emergency contact information for the residents have been updated.

During the tour, LPA observed unlocked medications in a cabinet. LPA was informed that the lock on the cabinet was broken. This poses an immediate health & safety risk to the residents in care. The licensee
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Christine LeTELEPHONE: (951) 897-2618
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021
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
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: TRUE FAMILY CARE
FACILITY NUMBER: 331880494
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/16/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation & interview, the licensee did not comply with the section cited above which poses an immediate health & safety risk to the residents in care. The licensee did not ensure centrally stored medications were kept in a safe and locked place. During the tour, LPA observed unlocked medications in a cabinet. LPA was informed that the lock on the cabinet was broken.
POC Due Date: 07/17/2021
Plan of Correction
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The licensee shall ensure centrally stored medications are locked and inaccessible when not in use. Proof will be submitted by the Department by 7/17/21.
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: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Christine LeTELEPHONE: (951) 897-2618
LICENSING EVALUATOR SIGNATURE:
DATE: 07/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2021
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: TRUE FAMILY CARE
FACILITY NUMBER: 331880494
VISIT DATE: 07/16/2021
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shall ensure medications are locked and inaccessible when not in use.

Refer to LIC809D for deficiency cited. An exit interview was conducted where this report, LIC809D, and appeal rights were discussed and provided to the administrator.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Christine LeTELEPHONE: (951) 897-2618
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021
LIC809 (FAS) - (06/04)
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