331880557-3-18-2024-18-AS-CCON-D3GQBY-20240318120218

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880557
Report Date: 03/18/2024
Date Signed: 03/18/2024 12:02:32 PM

Document Has Been Signed on 03/18/2024 12:02 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:	RAINBOW VIEW SENIOR CARE LPA,LLC		FACILITY NUMBER:	331880557
ADMINISTRATOR:	LORENA ALANDY		FACILITY TYPE:	740
ADDRESS:	4170 RAINBOW VIEW WAY		TELEPHONE:	(949) 290-8661
CITY:	HEMET	STATE: CA	ZIP CODE:	92545
CAPACITY:	6	CENSUS: 3	DATE:	03/18/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Lorena Alandy - Administrator/Licensee		TIME COMPLETED:	12:15 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) Crystal Colvin arrived at the facility unannounced for the purpose of conducting the annual inspection. LPA Colvin met with Administrator/Licensee Lorena Alandy and informed her of the purpose of today's inspection. Below is a summary of what was observed: Infection Control: LPA Colvin observed that the facility has an updated Infection Control Plan on file and is demonstrating best practices in the facility to maintain a healthy environment for staff and residents. Such measures include: soap and paper towels at hand washing stations, hand washing guides posted, and tight-fitting lids on trash cans. Physical Plant: LPA Colvin toured the facility and observed that there a sufficient bedrooms and bathrooms for both staff and residents. LPA Colvin observed the required furniture and linen to be present and in good condition in resident bedrooms. LPA Colvin measured the hot water in the bathroom faucets to be 118.9 degrees in the master bathroom and 124.1 degrees in the hallway bathroom. Deficiency cited. LPA Colvin observed staff testing the facility's carbon monoxide alarm and smoke detectors and found them to be operational. LPA Colvin observed that sharp objects like knives were locked away from residents' reach in a drawer in the kitchen. LPA Colvin toured the backyard and confirmed that no exits or pathways were blocked. LPA Colvin observed sufficient supply of perishable and non-perishable food and utensils and dishes for the residents in care. LPA Colvin observed cameras in the common areas of the facility, which are not included in the facility's Plan of Operation. Deficiency cited. LPA Colvin informed Administrator/Licensee of items that needed to be addressed in the updated Plan of Operator for the use of cameras, as well as them needing to add a consent form to their Admissions Agreement. Operational Requirements: LPA Colvin observed the facility to be operating within their licensed capacity of 6 non-ambulatory residents, one of which may be bedridden. Facility has a hospice waiver for 6 residents.

SUPERVISOR'S NAME: Tricia Danielson	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024

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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: RAINBOW VIEW SENIOR CARE LPA,LLC	FACILITY NUMBER: 331880557
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.618(a)

Other Provisions

(a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview], the licensee did not comply with the section cited above in 1 of 1 Administrators, which poses an immediate safety or personal rights risk to persons in care. LPA Colvin confirmed that the facility's Administrator was out of the country for 6 months and did not notify the Department of an appointed replacement.
	POC Due Date: 03/19/2024
	Plan of Correction
1 2 3 4	Licensee agrees to review the regulations for Administrator Duties, as well as Health and Safety Code section cited, and provide LPA Colvin with a Statement of Understanding regarding such. Plan of Correction date 3/19/24.

Type A

Section Cited

CCR

87458(a)

Medical Assessment

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. 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 in 1 of 3 residents (R1), which poses an immediate health risk to persons in care. LPA Colvin observed that while R1 has been in the facility since September 2023, the facility does not have a Physician's Report on file for R1.
	POC Due Date: 03/19/2024
	Plan of Correction
1 2 3 4	Licensee agrees to make plan for obtaining a Physician's Report for R1 as soon as possible. Licensee to consider finding out where R1 lived prior and obtaining a copy of that report until a new one can be created. Licensee to provide LPA Colvin with proof of effort and estimated date for procurement of new Physician's Report. Plan and proof of efforts due to LPA Colvin by Plan of Correction date of 3/19/24.

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 Danielson	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024

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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: RAINBOW VIEW SENIOR CARE LPA,LLC	FACILITY NUMBER: 331880557
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87208(a)

Plan of Operation

(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in1 aspect of their Plan of Operation (cameras in facility), which poses a potential personal rights risk to persons in care. LPA Colvin observed cameras in the common areas of the facility.
	POC Due Date: 04/01/2024
	Plan of Correction
1 2 3 4	Licensee agrees to update Plan of Operation and provide update to LPA Colvin by Plan of Correction date of 4/1/24.

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. 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 in 3 of 4 quarterly diaster drills, which poses a potential safety risk to persons in care. LPA Colvin observed that the facility has not conducted a disaster drill since July 2023.
	POC Due Date: 04/01/2024
	Plan of Correction
1 2 3 4	Licensee agrees to conduct an Emergency Disaster Drill as well as formulate a plan to ensure they are conducted quarterly, as required. Licensee to provide LPA Colvin with copy of the completed Disaster Drill along with their plan to ensure completion of them each quarter. Due by Plan of Correction date of 4/1/24.

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 Danielson	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024

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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: RAINBOW VIEW SENIOR CARE LPA,LLC	FACILITY NUMBER: 331880557
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(e)(2)

Other Provisions

(e) A facility shall have all of the following information readily available to facility staff during an emergency: (2) An appraisal of resident needs and services plan for each resident. 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 in [count] out of 1 of 3 residents (R1) which poses a potential health and safety risk to persons in care. LPA Colvin observed an incomplete Needs and Services Plan in file for R1, which did not indicate what R1's needs were or how the facility will provide for them
	POC Due Date: 04/01/2024
	Plan of Correction
1 2 3 4	Licensee agrees to complete a new Needs & Services Plan for R1 which is thurough and complete. A copy of the Plan is to be provided to LPA Colvin by Plan of Correction date of 4/1/24.

Type B

Section Cited

HSC

1569.695(e)(3)

Other Provisions

(e) A facility shall have all of the following information readily available to facility staff during an emergency: (3) A resident medication list for residents with centrally stored medications. 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 in 1 of 3 residents, which poses a potential health risk to persons in care. LPA Colvin observed that the facility does not have an updated/current Centrally Stored Medication log for R1.
	POC Due Date: 04/01/2024
	Plan of Correction
1 2 3 4	Licensee agrees to update R1's Centrally Stored Medication Log and additionally properly dispose of all discontinued medications (record of this shall also be kept on file). Licensee to provide LPA Colvin with an updated Centrally Stored Medication Log by Plan of Correction date of 4/1/24.

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 Danielson	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024

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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: RAINBOW VIEW SENIOR CARE LPA,LLC	FACILITY NUMBER: 331880557
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(E)(2)

Maintenance and Operation: (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 1 of 2 bathroom sinks (common area bathroom sink) which poses an immediate health and safety risk to persons in care. LPA Colvin observed the hallway bathroom faucet to have hot water measuring at 124.1 degrees.
	POC Due Date: 03/19/2024
	Plan of Correction
1 2 3 4	Administrator agrees to adjust hot water tempurature and remeasure the hot water in all faucets to ensure it is within the required range. Administrator may self-certify to LPA Colvin once complete. Due by Plan of Correction date of 3/19/24.

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: Tricia Danielson	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024

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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: RAINBOW VIEW SENIOR CARE LPA,LLC	FACILITY NUMBER: 331880557
	VISIT DATE: 03/18/2024

NARRATIVE

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Staffing & Staff Records: LPA Colvin confirmed that there are sufficient staff present to meet the needs of residents. LPA Colvin additionally confirmed that the facility has an Administrator with a current Administrator Certificate. LPA Colvin learned while at the facility that the Administrator recently returned from a six-month trip out of the country. Licensing was not notified of the absence of the Administrator and advised on who would be present to oversee the facility during this time. Deficiency cited. LPA Colvin reviewed staff records and confirmed current CPR/First Aid Certification as well as training relevant to the facility and residents' needs.

Resident Records: LPA Colvin reviewed the files for all 3 current residents to confirm that they have the required information present in their files, including Physician's Report, Admissions Agreement, and current Needs & Services Plan. LPA Colvin observed that Resident 1 (R1) was admitted to the facility in September 2023 but does not have a Physician's Report on File. Deficiency cited. LPA Colvin additionally observed that R1's Needs & Services Plan is incomplete, as it merely states likes/dislikes of the resident, as well as their diagnosis, but does not indicate what they need from the facility or how staff will meet that need. Deficiency cited.

Incidental Medical Services: LPA Colvin observed that resident medication is locked in a cabinet in the kitchen and inaccessible to residents. LPA Colvin confirmed that the facility is not retaining any residents with prohibited health conditions. LPA Colvin observed that R1 does not have an updated Centrally Stored Medication Log, and the one on file with the facility does not have R1's most recently prescribed medications. Deficiency cited.

Planned Activities: LPA Colvin observed the facility's Activity Calendar as well as residents engaging in their own private activities in their rooms.

Emergency Disaster Preparedness: LPA Colvin confirmed that the facility has an Emergency Disaster Plan on file, though their last disaster drill was conducted in July 2023. Deficiency cited.

An exit interview was conducted with Administrator/Licensee Lorena Alandy and a copy of this report, LIC809D, LIC9098 Proof of Corrections, and appeal rights were provided.

SUPERVISOR'S NAME: Tricia Danielson	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024

LIC809 (FAS) - (06/04)

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