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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880725
Report Date: 05/20/2022
Date Signed: 05/20/2022 02:35:22 PM

Document Has Been Signed on 05/20/2022 02:35 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:TEMPLE HEIGHTSFACILITY NUMBER:
331880725
ADMINISTRATOR:HOBBS, ESTAFACILITY TYPE:
740
ADDRESS:26707 PADDINGTON CTTELEPHONE:
(951) 640-2606
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY: 6CENSUS: 4DATE:
05/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:13 PM
MET WITH:Licensee- Esta HobbsTIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA), Janira Arreola made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA was greeted and granted entry by licensee Esta Hobbs, who was informed of the purpose of the visit. At the time of visit there was 2 staff and 4 residents present. The facility currently has zero positive or suspected Covid-19 cases.

During today's visit, LPA toured the facility and made observations regarding the infection control measures that the facility has implemented. LPA observed Covid-19 postings at the facility. A single entry point was designated where symptoms screenings and temperature checks occur daily for all visitors, residents, and staff. The facility had a plan in place to monitor residents regularly for any changes in condition. The facility had an adequate amount of hand hygiene supplies (soap, hand sanitizer, paper towels) in all restrooms. Common areas such as dining rooms and activity rooms have been modified with social distancing and masking policies. There are designated isolation rooms and a plan in place to monitor and attend to those in the isolation rooms. LPA observed a sufficient 30-day supply of PPE equipment. The facility also has a designated infection control lead and a plan in place to clean and disinfect the highly touched surfaces.
LPA advised Licensee to provide the department with a copy of the facility Mitigation plan. LPA was able to review and sign the plan by the end of the visit.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2022
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: TEMPLE HEIGHTS
FACILITY NUMBER: 331880725
VISIT DATE: 05/20/2022
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LPA was greeted by S1 who was not on the roster. LPA requested clearance number for S1 and verified that the staff was cleared. Licensee was able to provide LPA with documentation of mailed transfer sheet LIC9182 that was mailed to the department on 1/3/2021. LPA will send licensee an e-mail about the Guardian system to make sure all staff have been associated.

During the tour of the facility LPA and Licensee noticed the following deficiencies:
· LPA observed unlocked chemicals in bathroom 3. LPA will issue a Type B citation for this.

· LPA was unable to see inside of Office space room at the facility. Licensee did not have a key and the door and window to the room did not have a clear view of the inside. LPA will issue a Type B citation for this.


An exit interview was conducted, and a copy of this report and appeal rights were provided to facility licensee, Esta Hobbs.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/20/2022 02:35 PM - It Cannot Be Edited


Created By: Janira Arreola On 05/20/2022 at 02:08 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: TEMPLE HEIGHTS
FACILITY NUMBER: 331880725

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(g)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above with chemicals that were being kept under the bathroom skin in bathroom 3. This poses safety risk to persons in care.
POC Due Date: 05/30/2022
Plan of Correction
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Licensee will send e-mail that staff have been reminded to keep chemicals locked and photo of removed chemicals.
Type B
Section Cited
CCR
80044


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not being able to provide LPA access to office. Licensee did not have a key to open the room and LPA was not able to have a clear view of the inside from the door or the window. This poses a potential safety risk to persons in care.
POC Due Date: 05/30/2022
Plan of Correction
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Licensee will send a photo of the inside of the office and an e-mail about the plan to have access to a key at all times to the locked office.
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:Joel Esquivel
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2022


LIC809 (FAS) - (06/04)
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