331880508-7-28-2023-18-AS-JROO-CU6SR9-20230728140558

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880508
Report Date: 07/28/2023
Date Signed: 07/28/2023 02:06:09 PM

Document Has Been Signed on 07/28/2023 02:06 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	EMPATHY		FACILITY NUMBER:	331880508
ADMINISTRATOR:	BANSODE, HEMALATA		FACILITY TYPE:	740
ADDRESS:	17312 RIVA RIDGE		TELEPHONE:	(951) 323-0536
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92555
CAPACITY:	6	CENSUS: 6	DATE:	07/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Administrator Hemalata Bansode		TIME COMPLETED:	02:15 PM

NARRATIVE

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On 7/28/2023, at 11:30 a.m., Licensing Program Analyst (LPA) Janette Romero arrived unannounced at the facility to conduct an annual required visit. LPA was greeted and granted entry by Caregiver Barinder Kaur who was informed of the purpose of visit. Administrator Hemalata Bansode arrived during the visit. The facility is approved for three (3) ambulatory and three (3) non-ambulatory residents, of which one may be bedridden. Facility has a hospice waiver for three (3) residents. During the visit, there was four (4) residents and (1) staff present. LPA toured the facility’s interior and exterior with Caregiver Kaur, and observed the following:

Kitchen: LPA observed kitchen to be clean. Food is stored in a safe and healthful manner. LPA observed the facility had sufficient perishable and non-perishable food items. Knives/sharps are secured in a locked kitchen cabinet.

Dining and Living room: LPA observed area to be clean and furniture in good condition. LPA observed a resident resting in the living room and the other residents sleeping in their rooms.

Hallway: LPA observed hallway to be clean with no pathway obstruction. Carbon monoxide & smoke detectors were tested and functioning properly. Fire extinguisher is charged and mounted on entrance hallway.

Bedrooms: Resident bedrooms were each furnished with a bed, chair, closet, clothing storage and lighting. During tour of Resident #1's bedroom, LPA observed R1's mattress was soiled/stained. Deficiency cited.

Continued on LIC809-C..

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette Romero	TELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: EMPATHY	FACILITY NUMBER: 331880508
	VISIT DATE: 07/28/2023

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Centrally Stored Medications: LPA observed a first aid kit with required components. Medications were secured in a cabinet near the kitchen. LPA reviewed physical medications and Medication Administration Record (MAR) for R1 and discovered there were no notations on R1's MAR for several dates in July 2023. LPA also observed that the medication hour column in R1's MAR had some corrections made with a White-Out pen/brush.

Administrator Bansode stated that R1 was at the facility on the dates in question and added that facility staff dispensed medication for R1 and must have forgotten to initial the MAR. Administrator Bansode stated that facility staff noted the wrong time in the medication hour column and used white-out to correct it. Deficiency cited.

Bathrooms: Bathrooms have a working toilet, wash basin, and were equipped with a grab bar in the shower. The hot water temperature measured at 107- and 108-degrees Fahrenheit. The facility has clean towels, blankets, and linen, available in different colors for the residents in care.

Records: Staff #1 (S1) present has a criminal record clearance on file, but is not associated to the facility. Civil penalty issued.

A blank copy of a Criminal Background Clearance Transfer Request (LIC9182) and the facility's current guardian roster was provided to Adminstrator Bansode for reference. Per Administrator Bansode, S1 has worked at the facility for approximately three (3) years. LPA verified S1 has a current CPR/first aid certification.

Yard/Outside Area: A brick wall secured the backyard. All outdoor pathways were free of obstructions. No bodies of water were observed.

Based on the aforementioned, LPA issued a civil penalty along with two (2) deficiencies faulting the facility.

An exit interview was conducted, and a copy of this report was reviewed and provided to Administrator Bansode along with an LIC809-D, LIC421BG, and Appeals Rights.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette Romero	TELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/28/2023 02:06 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: EMPATHY	FACILITY NUMBER: 331880508
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87355(e)(3)

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above due to LPA observing Staff #1 (S1) present and reviewing records, which indicated S1 is not associated to the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/07/2023
	Plan of Correction
1 2 3 4	Facility agreed to submit Criminal Background Clearance Transfer Request (LIC9182) for S1 to CCLD and provide proof of correction by close of business on POC due date.

Type B

Section Cited

CCR

87307(a)(3)(C)

(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above due to LPA observing soiled/stained mattress in Resident #1's (R1's) bedroom, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/07/2023
	Plan of Correction
1 2 3 4	Facility agreed to clean/replace soiled/stained mattress observed in R1's bedroom and provide proof of practice to CCLD by close of business on 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: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette Romero	TELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 07/28/2023 02:06 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: EMPATHY	FACILITY NUMBER: 331880508
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(a)(4)

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by the discrepancies discovered by LPA on Resident #1's Medication Administration Record (MAR), which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/07/2023
	Plan of Correction
1 2 3 4	Facility agreed to provide staff training regarding dispensing medication and proper documentation of MAR. Proof of correction to be submitted to CCLD by close of business on POC due date.

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: Janette Romero	TELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

LIC809 (FAS) - (06/04)

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