331880585-6-26-2023-18-AS-CGOH-CT75U3-20230626201513

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880585
Report Date: 06/26/2023
Date Signed: 06/26/2023 08:15:20 PM

Document Has Been Signed on 06/26/2023 08:15 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:	COOL MEADOW CARE		FACILITY NUMBER:	331880585
ADMINISTRATOR:	MA SATCHEL LECITA		FACILITY TYPE:	740
ADDRESS:	29787 COOL MEADOW DR		TELEPHONE:	(951) 246-0214
CITY:	MENIFEE	STATE: CA	ZIP CODE:	92587
CAPACITY:	6	CENSUS: 6	DATE:	06/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	05:43 PM
MET WITH:	Liz Baclagan		TIME COMPLETED:	08:16 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) Cheryl Goodrich conducted an unannounced annual visit. LPA met with the caregiver Liz Baclagan at the front door and was granted entry.The purpose of today’s visit is to inspect the facility to ensure that the facility is following California Code of Regulations, Title 22, Division 6. Facility is approved for five (5) ambulatory and residents of which one (1) non-ambulatory. The Facility has a hospice wavier with total care for two (2). Physical Plant: front entrance, interior and surrounding exterior were clean and in good repair with no pathway obstruction; doorway alarms were in working order; residents' main restroom water temperature read at 114.3 degrees; there were no bodies of water on premises; there was sufficient lighting and mattress pads in all of the residents' bedrooms; fire alarm were in working order. Facility does not house firearms and/or ammunition on grounds. Food Services: 7-day non-perishable and 2 day of perishable food supply was observed and all food was properly stored and available to residents. Medication/Facility Records: Medications were observed to be labeled and in a locked place that is inaccessible to residents. All staff subject to a criminal record review obtained fingerprint clearance and/or an exemption. Staff responsible for direct care and supervision have current First Aid / CPR training. Licensee has completed a written admission agreement, current medical assessment and needs and service plan with each resident. Exceptions & waivers are in place and meet said terms. Licensee handles no resident cash resources.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Cheryl Goodrich	TELEPHONE: 951-248-0308
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2023

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: COOL MEADOW CARE	FACILITY NUMBER: 331880585
	VISIT DATE: 06/26/2023

NARRATIVE

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Care & Supervision/Administration: Adequate staff are present for the supervision of clients. Emergency exiting plans, telephone numbers and personal rights were found posted in the facility. The listed administrator possesses a current administrator's certificate.

Forms: The following signs were observed to be posted at the home: Emergency Disaster Plan (LIC 610E), Personal Rights, and Facility Sketch (LIC 999).

Deficiencies Notes: The Carbon Monoxide Detector was removed. There is a new employee who has not been trained on any procedure and does not speak English to be able to communicate with Residents or Emergency. Residents are not given activities to enhance their quality of care with their Dementia and their well being.

An exit interview was conducted, and a copy of this report was reviewed and provided to Caregiver Liz Baclagan.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Cheryl Goodrich	TELEPHONE: 951-248-0308
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/26/2023 08:15 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: COOL MEADOW CARE	FACILITY NUMBER: 331880585
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.311

Regulations

Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and testimony given by Liz Baclagan, the licensee did not comply with the section cited above in zero out of one Carbon Monoxide detector in the facility which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/30/2023
	Plan of Correction
1 2 3 4	Staff, Liz Baclagan states the Administrator will provide a Carbon Monoxide Detector in the facility.

Section Cited


	Deficient Practice Statement
1 2 3 4	Staff states the Administrator will continue to provide Carbon Monoxide detectors in the facility and train on the installing Carbon Monoxide training.
	POC Due Date: 06/30/2023
	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: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Cheryl Goodrich	TELEPHONE: 951-248-0308
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2023

LIC809 (FAS) - (06/04)

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