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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880585
Report Date: 05/04/2023
Date Signed: 05/04/2023 10:36:22 AM


Document Has Been Signed on 05/04/2023 10:36 AM - 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: 5DATE:
05/04/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:28 AM
MET WITH:John Zhang - LicenseeTIME COMPLETED:
10:43 AM
NARRATIVE
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit at the facility for the purpose verifying a Plan of Correction (POC). LPA met with care staff Liz Baclagan who was informed of the reason for today's visit and who phoned the licensee. Licensee John Zhang arrived shortly and phoned administrator Ma Satchel Lecita who spoke with LPA.

On 04/24/2023, the facility was issued a deficiency was issued due to two incomplete physician's report in resident's files. During today's visit, LPA confirmed that both records are complete. LPA Bueno has determined that the plan of correction has been met.
The facility received a Letter of Deficiency Citation Cleared for the deficiency cleared during inspection.

During today's visit, LPA confirmed that R1 is not receiving hospice care services. On 04/24/2023, LPA observed that R1's bed has full bed rails however R1's records were incomplete. LPA observed during today's visit that R1 is kept on full bed rails therefore a deficiency is issued. Refer to LIC 809D for deficiency cited.

An exit interview was conducted where this report, LIC 809D, and appeal rights were discussed with and provided to licensee John Zhang
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2023
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 05/04/2023 10:36 AM - 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: 05/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/11/2023
Section Cited

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(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.
This requirement was not met as evidenced by:
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Licensee shall immediately remove full bed rails on R1's bed and can instead install half-rails.

LPA observed licensee remove full bed rails and install half-rails during today's visit. This POC was satisfied.
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LPA observed that R1's bed has full bed rails. Administrator confirmed that R1 is not receiving hospice services. This poses an immediate health, safety, and personal rights 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: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2023
LIC809 (FAS) - (06/04)
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