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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880566
Report Date: 01/27/2022
Date Signed: 01/27/2022 02:16:53 PM

Document Has Been Signed on 01/27/2022 02:16 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:FIRST CHOICE SENIOR LIVINGFACILITY NUMBER:
331880566
ADMINISTRATOR:RECINTO, MONTANO OFACILITY TYPE:
740
ADDRESS:34796 MYOPORUM LNTELEPHONE:
(951) 599-4305
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY: 6CENSUS: 5DATE:
01/27/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:38 AM
MET WITH:Licensee, Montano RecintoTIME COMPLETED:
02:30 PM
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On 1/27/22 Licensing Program Analysts (LPA) David Cuevas and Licensing Program Manager (LPM) Deborah Mullen arrived at the residence to check on the Health and Safety of residents. Upon arrival, LPAs met with Licensee, Montano Recinto and explained the purpose of the visit, who allowed entry.

During visit LPA’s conducted a record review of resident files, reviewed resident medications and conducted an inspection of the facility. The following are deficiencies that were identify.

· Front door has a keyed dead bolt, which LPA’s observed being locked by staff.

· Fire Safety concerns- LPA’s observed a hall closet and a pantry next to kitchen being used as staff bedrooms.

· Medication Issues- LPA’s observed medication being dispensed from a daily pill container instead of from the prescription container.

· Client records- Records were incomplete missing several required documents, as well as physicians report missing responsible parties’ signatures.

Based on observations and records review the facility will be cited deficiencies and civil penalties accessed.

An exit interview was conducted with Licensee, Montano Recinto were this report, LIC 9099D, and appeal rights were reviewed with and provided to Mr. Recinto.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: David Cuevas
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2022
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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Document Has Been Signed on 01/27/2022 02:16 PM - It Cannot Be Edited


Created By: David Cuevas On 01/27/2022 at 12:11 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: FIRST CHOICE SENIOR LIVING
FACILITY NUMBER: 331880566

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/27/2022
Section Cited
CCR
87468.1(a)(6)

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(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night...This requirement was not being met as evidenced by:
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Licensee will removed deadbolt located in the front door and provide proof of correction by 5:00pm on 1/27/2022.
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During visit to facility on 1/27/2022, LPA's observed the front door to have a keyed deadbolt prevently individuals from exiting the facility.This poses an immediate health and safety risk to residents in care.
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Type A
01/27/2022
Section Cited
CCR87203

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Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic...This requirement was not being met as evidenced by:
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Licensee will immidiately cease using hall closet and kitchen pantry as staff bedrooms by 5PM on 1/27/2022
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During a facility inspection on 1/27/2022, LPA's observed a hall closet and the kitchen pantry being used as staff bedrooms. This poses a potential health and safety risk.
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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:Joel Esquivel
LICENSING EVALUATOR NAME:David Cuevas
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2022


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Document Has Been Signed on 01/27/2022 02:16 PM - It Cannot Be Edited


Created By: David Cuevas On 01/27/2022 at 12:26 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: FIRST CHOICE SENIOR LIVING
FACILITY NUMBER: 331880566

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)

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Type B
02/03/2022
Section Cited
CCR87465(h)(5)

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(h) The following requirements shall apply to medications which are centrally stored:(5)Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.This requirement is not met evidence by:
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Licensee will conduct training with staff to review regulation requirements with current and newly hired staff and submit proof of training by due date 2/3/22
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LPA observed Resident #6's medications to be stored in a daily pill container rather than the prescription bottle. This poses an immediate health and safety risk to residents in care.
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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:Joel Esquivel
LICENSING EVALUATOR NAME:David Cuevas
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/27/2022 02:16 PM - It Cannot Be Edited


Created By: David Cuevas On 01/27/2022 at 12:40 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: FIRST CHOICE SENIOR LIVING
FACILITY NUMBER: 331880566

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/03/2022
Section Cited
CCR
87506(a)

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87506(a) Resident Records. A separate, complete, and current record shall be maintained for each resident in the facility, readily available to facility staff and to licensing agency staff and shall contained specified information.This requirement was not met evidence by:
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Licensse will conduct an audit of current resident records and update as necessary. Proof of audit and updates must be presented to CCL by due date
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Based on a review of resident records, Resident #1 through #5 were incomplete and missing required documents. This poses an immediate health and safety risk to residents in care.
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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:Joel Esquivel
LICENSING EVALUATOR NAME:David Cuevas
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2022


LIC809 (FAS) - (06/04)
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