331880616-12-4-2023-18-AS-JGEE-CY83BM-20231204170635

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880616
Report Date: 12/04/2023
Date Signed: 12/04/2023 05:06:44 PM

Document Has Been Signed on 12/04/2023 05:06 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:	ANNA CARE LLC		FACILITY NUMBER:	331880616
ADMINISTRATOR:	BLANCAFLOR, ANNALISA		FACILITY TYPE:	740
ADDRESS:	26461 RIDGEMOOR RD		TELEPHONE:	(951) 309-1623
CITY:	SUN CITY	STATE: CA	ZIP CODE:	92586
CAPACITY:	6	CENSUS: 5	DATE:	12/04/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Annalisa Blancaflor, Administrator		TIME COMPLETED:	05:15 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	On 12/04/23 Licensing Program Analyst (LPA) Javina George arrived unannounced to the facility noted above to conduct an annual inspection. LPA was greeted and granted entry by Caregiver Bituin Mendoza. LPA met with the Administrator Annalisa Blancaflor, who arrived after LPAs arrival. Below is an account of LPAs observations of the conducted inspection: Physical plant: The facility was observed to be within the licensed capacity (6). At the time of LPAs visit all residents were asleep taking their afternoon naps. LPA was able to successfully conduct one (1) resident interview. LPA was unable to check the mattresses. LPA observed for the resident bedrooms to have night stands, storage space, and sufficient lighting. The facility temperatures were comfortable for residents in care. LPA measured the hot water temperature in two (2) resident bathrooms, initially the water temperature was too hot, the water heater was adjusted and the water temperature ranges were retested and observed to be within regulatory limits of ranging from 115-117 degrees Fahrenheit. The carbon monoxide and smoke detectors were tested and were observed to be operable. The facility was stocked with a 2-day supply of perishable and 7-day supply of non-perishable food items that were labeled appropriately. Personnel: The facility administrator certificate expired and the renewal packet was sent off the month after it was due (10/2023). The administrator will send proof of completion to the department by 5pm on 12/5/23. In addition the Administrator's CPR/First Aid expired on 06/19/2020. Deficiency cited.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023

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 12/04/2023 05:06 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: ANNA CARE LLC	FACILITY NUMBER: 331880616
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.695(a)

Other Provisions

(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above 1 out of 1 times which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/05/2023
	Plan of Correction
1 2 3 4	The licensee agrees to complete the LIC610E and submit it to the department by 5pm tomorrow (12/5/23).

Type A

Section Cited

HSC

1569.269(c)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios... While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.
	POC Due Date: 12/05/2023
	Plan of Correction
1 2 3 4	Based on observation, the licensee did not comply with the section cited above 2 out of 3 times which poses an immediate health, safety or personal rights risk to persons in care.The licensee agrees to conduct a disaster drill, proof of POC correction is to be submitted, to the department by 5pm tomorrow (12/5/23).

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: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023

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: ANNA CARE LLC	FACILITY NUMBER: 331880616
	VISIT DATE: 12/04/2023

NARRATIVE

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There is a locked and centralized storage area for medications, which is located in the kitchen above the microwave. The facility had a designated area for resident files and staff files, however there were no other staff files available for review but the Administrator's. Per the Administrator the facility is in the process of updating the staff files which is why they were not at the facility. The administrator is to submit proof of staff #1 (S1) employee file to the department by 5:00pm on 12/5/23. All staff present have a criminal record clearance on file and are associated to the facility. The facility was not observed to have all the required postings however did have such as Ombudsman poster and PUB475. See citations below.

The facility was also equipped with one (1) fire extinguisher and one (1) complete first aid kit as well as the first aid manual. LPA inspected the outdoor area of the facility. The facility has a covered patio. The facility is in compliance as the business' governing body is active and functioning. The licensing renewal fees are due by 12/18/23, and was discussed with the Administrator.

The following citation(s) are being issued as the facility has not been conducting emergency disaster drills on a quarterly basis nor documenting the conducted drills. In addition the facility did not have personnel files available for review at the time of LPAs visit. The administrator's CPR/First Aid expired 06/19/2020. Further the facility does not have a completed Emergency Disaster Plan (LIC 610E). The citation(s) can be found on the attached 809D.

An exit interview was conducted and a copy of the report, 809D, and appeal rights were reviewed and provided to Annalisa Blancaflor, administrator.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/04/2023 05:06 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: ANNA CARE LLC	FACILITY NUMBER: 331880616
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.618(c)

This requirement is not met as evidenced by: (c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on file review, the licensee did not comply with the section cited above in 1 out of 1 times which poses an immediate health & safety risk to the residents in care. LPA observed that the administrator's first aid/CPR certification is expired. The administrators first aid/CPR certification expired in September 2020.
	POC Due Date: 12/05/2023
	Plan of Correction
1 2 3 4	The licensee agrees to submit proof of completed of CPR/First Aid training to the department by 5pm on the due date indicated 12/5/23.

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: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/04/2023 05:06 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: ANNA CARE LLC	FACILITY NUMBER: 331880616
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(f)

87412 Personnel records (f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above in 1 of of 1 times which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/18/2023
	Plan of Correction
1 2 3 4	The licensee agrees to submit S1's employee file to the department by 5pm on the due date indicated (12/5/23).

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: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023

LIC809 (FAS) - (06/04)

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