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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880616
Report Date: 11/14/2024
Date Signed: 11/14/2024 04:41:45 PM

Document Has Been Signed on 11/14/2024 04:41 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:ANNA CARE LLCFACILITY NUMBER:
331880616
ADMINISTRATOR/
DIRECTOR:		BLANCAFLOR, ANNALISAFACILITY TYPE:
740
ADDRESS:26461 RIDGEMOOR RDTELEPHONE:
(951) 309-1622
CITY:SUN CITYSTATE: CAZIP CODE:
92586
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
11/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Wilnekka Bradford, House ManagerTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction, visit purpose and provided the facility caregiver with LPA identification and business card. Infection Control plan on file. House Manager arrived after LPA's arrival.

Resident record review began- Four (4) records were reviewed. LPA reviewed for admission agreement, medical assessment and TB test results, consent forms, identification and emergency information, appraisal needs and service plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. This facility is meeting documentation requirements.

Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. The home is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured 111.0 degrees F. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals; cleaning supplies observed on the ground. All outdoor and indoor passageways are free of obstruction. A locked area is provided for medications and sharp objects. LPA verified there is a telephone working at this location.



Food Service- Food supply meets the requirement of one week supply of nonperishable and 2 day supply of perishables food on hand. A menu is posted, foods are dated to assure safety. Food prep areas are clean and organized.

LPA began review of employee records- Two (2) records were reviewed. LPA reviewed employee record for first aid certification, fingerprint clearance, personnel/job application, health screening-1 misssing and TB (Continued on next page)
Jazmond D HarrisTELEPHONE: (951) 248-0318
Yolanda DelgadoTELEPHONE: (951) 203-2990
DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ANNA CARE LLC
FACILITY NUMBER: 331880616
VISIT DATE: 11/14/2024
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test results, criminal record statement, employee rights, training verification, and current administrator certification. CPR and requirements have been met. The facility employs enough staff to maintain cleanliness and meet the needs of the clients in care. Administrator certification is not present and is not current.

LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. The facility has not exceeded its capacity limitation and the structure remains unchanged according to the approved floor plan. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguishers are tested or replaced annually and were last done so on 11/2024. The facility is conducting emergency disaster drills. The last disaster drill was conducted on 02/2024, documentation requested and unable to be provided. No firearms are stored on premises and no bodies of water observed.

LPA allocated time to prepare this report for delivery.

Based on the information received during this visit today, there are five (5) deficiencies that are being cited per Title 22, Division 6 of The California Code of Regulations.

This report was reviewed with and a copy provided to the facility representative. Appeal Rights were also provided at the time of the exit interview.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda DelgadoTELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/14/2024 04:41 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: ANNA CARE LLC
FACILITY NUMBER: 331880616

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in S1 did not have a health screening observed in staff file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2024
Plan of Correction
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2
3
4
Licensee will ensure S1 obtains a health screening and email copy to LPA by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Jazmond D HarrisTELEPHONE: (951) 248-0318
Yolanda DelgadoTELEPHONE: (951) 203-2990

DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/14/2024 04:41 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: ANNA CARE LLC
FACILITY NUMBER: 331880616

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Personnel Records
(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in Administrator does not have a current valid Adminstrator certificate; expired as of 09/09/2023 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2024
Plan of Correction
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2
3
4
Licensee will send documentation of status of Adminstrator certificate by email to LPA by POC due date.
Section Cited
Planned Activities
(h) Facilities shall provide sufficient space to accommodate both indoor and outdoor activities. Activities shall be encouraged by provision of: (2) Outdoor activity areas which are easily accessible to residents and protected from traffic. Gardens or yards shall be sufficient in size, comfortable, and appropriately equipped for outdoor use.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA Delgado's observation, and interview, the licensee did not comply with the section cited above in no outdoor table and shade observed for clients use which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2024
Plan of Correction
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Licensee will obtain patio furniture and email photograph to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Jazmond D HarrisTELEPHONE: (951) 248-0318
Yolanda DelgadoTELEPHONE: (951) 203-2990

DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024

LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 11/14/2024 04:41 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: ANNA CARE LLC
FACILITY NUMBER: 331880616

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Other Provisions
(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. An actual evacuation of residents is not required during a drill. 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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in no documentation of drills for emergency scenarios were observed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2024
Plan of Correction
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3
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Licensee will create a plan of dates for emergency diaster drills and implement for the facility and email a copy to LPA by POC due date.
Section Cited


This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA Delgado's observation and interview, the licensee did not comply with the section cited above in cleaning supplies of laundry soap and Clorox bleach were observed on the ground next to the laundry machines inside the room that has no door to be secured; both items were not secured and accessible to clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2024
Plan of Correction
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2
3
4
Licensee will conduct staff training and ensure that cleaning solutions are locked, secured and not accessible to clients and email training sheet to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Jazmond D HarrisTELEPHONE: (951) 248-0318
Yolanda DelgadoTELEPHONE: (951) 203-2990

DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024

LIC809 (FAS) - (06/04)
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