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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880585
Report Date: 04/24/2023
Date Signed: 04/24/2023 02:38:55 PM


Document Has Been Signed on 04/24/2023 02:38 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:COOL MEADOW CAREFACILITY NUMBER:
331880585
ADMINISTRATOR:MA SATCHEL LECITAFACILITY TYPE:
740
ADDRESS:29787 COOL MEADOW DRTELEPHONE:
(951) 246-0214
CITY:MENIFEESTATE: CAZIP CODE:
92587
CAPACITY:6CENSUS: 6DATE:
04/24/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:04 PM
MET WITH:TIME COMPLETED:
02:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Anna Bueno conducted a subsequent unannounced visit to this facility to continue investigation of complaint numbers: 18-AS-20200724130142 AND 18-AS-20200723084004. LPA met with Licensee John Zhang.

During today's visit, LPA reviewed pertinent records and interviewed residents and staff. While interviewing Resident 1 (R1) who requested for a fresh brief, LPA observed that R1 was wearing two briefs. Staff interview stated that R1 received a stool softener and may have an irregular bowel movement. LPA reviewed R1 medication administration record (MAR) and found that R1 is receiving a scheduled laxative and there is no record of a PRN (as needed) stool softener administered today. LPA reviewed R1 records and found incomplete physician's reports.

This pose a potential health and safety risk to residents in care. Refer to LIC 809D for deficiency cited. A technical advisory is being issued regarding managing incontinent residents. An exit interview was conducted where this report, LIC809-D, and appeal rights were discussed with and provided to Licensee.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2023
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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Document Has Been Signed on 04/24/2023 02:38 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: COOL MEADOW CARE
FACILITY NUMBER: 331880585

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/01/2023
Section Cited

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87458 Medical Assessment (1)(b) (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious diseases or other medical conditions which would preclude care of the person by the facility.
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Licensee shall complete the physician's report in its entirety, specifically sections 7 through 9 of the LIC 602, physician's report. Licensee shall submit proof of correction no later than the end of POC date.
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This requirement was not met as evidenced by:
LPA reviewed two LIC602, physician's report from R1's file and neither forms list a primary and secondary diagnosis/es. This poses a potential health, safety, and personal rights risk to resident 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: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2023
LIC809 (FAS) - (06/04)
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