331880606-3-18-2024-18-AS-SMAZ-D3GUAQ-20240318152506

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880606
Report Date: 03/18/2024
Date Signed: 03/18/2024 03:25:16 PM

Document Has Been Signed on 03/18/2024 03:25 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:	ELLERY'S FAMILY CARE LLC		FACILITY NUMBER:	331880606
ADMINISTRATOR:	ELLERY JANE LUCENA		FACILITY TYPE:	740
ADDRESS:	11241 DEVINE CIR		TELEPHONE:	(951) 729-6006
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92503
CAPACITY:	6	CENSUS: 6	DATE:	03/18/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:23 PM
MET WITH:	Leandro Valenzuela - Caregiver		TIME COMPLETED:	03:35 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) Sara Martinez conducted an unannounced annual required visit . LPA was granted entry and met with caregiver Leondro Valenzuela who was informed of the purpose of the visit. Licensee Ellery Jane arrived during LPA's visit. At the time of the visit there was two (2) staff and six (6) residents present. The facility has a hospice waiver for six (6) residents. A dementia program is also on file. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following: Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. LPA observed outdoor furniture and shaded area for residents. LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. Facility contained PPE equipment and cleaning supplies to do regular cleaning of the facility. Cleaning supplies and detergents were locked and inaccessible to residents. The sharp and dangerous objects was locked and inaccessible to residents. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The smoke detector and carbon monoxide was operational, and the hot water temperature was recorded at 108 degree F, which met department requirements. Facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods. LPA reviewed two (2) staff files and training. All staff have the required personnel records on file and criminal record clearance and updated training along with CPR/First Aid Certification. The listed administrator possesses a current administrator's certificate.

SUPERVISOR'S NAME: Tricia Danielson	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Sara Martinez	TELEPHONE: (951) 605-0913
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: ELLERY'S FAMILY CARE LLC	FACILITY NUMBER: 331880606
	VISIT DATE: 03/18/2024

NARRATIVE

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Six (6) resident files were reviewed, and possessed all required paperwork that included Admissions Agreement, Physician's Report, and Needs and Service Plan.
LPA's record review of the resident files revealed Resident One (R1) Physician Report on file was last dated on 03/25/2022. Licensee did not have an updated Physician's Report for R1. Residents diagnosed with Dementia must have an updated Physician's Report completed annually. A deficiency cited under Title 22 Regulation 87705(c)(5) Care of Persons with Dementia will be issued along with a plan of correction.

Resident medication was centrally stored and locked in a cabinet in the dining room area. LPA reviewed medications for four (4) residents and found all medication listed on MARs and all required labeling was found to be in place.

LPA reviewed the facility's emergency and disaster plan. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies in the garage and first aid kit with all required items. Fire extinguishers were fully charged and inspected.

No deficiencies were cited at the time of the visit.

An exit interview was conducted where a copy of this report, LIC 809-D, appeal rights, and technical assistance was provided to Licensee Ellery Jane.

SUPERVISOR'S NAME: Tricia Danielson	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Sara Martinez	TELEPHONE: (951) 605-0913
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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Document Has Been Signed on 03/18/2024 03:25 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ELLERY'S FAMILY CARE LLC	FACILITY NUMBER: 331880606
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(c)(5)

87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in having R1's physician's report updated annually with the last report dated 03/25/2022 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/05/2024
	Plan of Correction
1 2 3 4	Licensee shall obtain an updated Physician's Report for R1 and submit a copy to LPA by the Plan of Correction date of 04/05/24.

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: Sara Martinez	TELEPHONE: (951) 605-0913
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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