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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880725
Report Date: 05/10/2024
Date Signed: 05/10/2024 02:23:12 PM

Document Has Been Signed on 05/10/2024 02:23 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:TEMPLE HEIGHTSFACILITY NUMBER:
331880725
ADMINISTRATOR/
DIRECTOR:		HOBBS, ESTAFACILITY TYPE:
740
ADDRESS:26707 PADDINGTON CTTELEPHONE:
(951) 640-2606
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY: 6CENSUS: 5DATE:
05/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:05 PM
MET WITH:Esta Hobbs, LicenseeTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Jacqueline Shaw Ross made an unannounced visit to the facility for the purpose of an annual review. LPA was greeted by Esperanza Igaye, Caregiver and explained the purpose of the visit. Administrator Esta Hobbs joined shortly. A tour of the facility was conducted inside and out. At the time of visit, all six (6) residents were home and two (2) staff were present. The facility is approved for six (6) elderly residents ages 60 and over, non-ambulatory, of which 1 may be bedridden. There is a hospice waiver for six (6) residents.

The facility is a five (5) bedroom three (3) bathroom one story home. One master bedroom is shared, two to a room. The other four (4) bedrooms are private rooms.

During the tour the following was observed: Resident bedrooms had the required furnishings and were observed to be in good condition. Bathrooms had required signage, hand rails, non-slip mats. Night-lights were observed in the hallways. Fixtures and furniture for an operational facility are present and in good repair. All passageways were free of obstructions, charged fire extinguishers and the fire alarm system was operable, medications are kept centralized and locked, hazardous items are kept inaccessible to residents. Hot water was tested at 106 degrees Fahrenheit. The backyard area is free of obstructions.

Kitchen/Food Service: LPA observed the entire kitchen, food is stored properly and dishes are clean and in good condition. There is a sufficient supply of perishable and non-perishable foods. Area was observed to be clean and functional.

Care & Supervision: Facility has sufficient care staff employed.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2024
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: TEMPLE HEIGHTS
FACILITY NUMBER: 331880725
VISIT DATE: 05/10/2024
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Administration: Emergency exiting plans, telephone numbers and Ombudsman information and other required signage are posted throughout the facility. Drills are conducted quarterly. The last drill was conducted 4/19/2024.

Record Review and Client/Staff Files: LPA reviewed current staff and all staff have has Criminal Background Clearance, current CPR/First Aid certification, and trainings are current. Client records were reviewed and all contain required documents and are up to date.

Medication Review: LPA reviewed medication and medication log. Residents' medications are being dispensed according to physician's orders however LPA observed the following deficiency:

**All resident medications were stored in pill containers. LPA informed Licensee per regulation, medication must be stored in it's original container. Deficiency cited.


An exit interview was conducted and a copy of this report along with LIC 809D, LIC 811 and a copy of Appeal Rights were provided to Licensee Esta Hobbs.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/10/2024 02:23 PM - It Cannot Be Edited


Created By: Jacqueline Shaw Ross On 05/10/2024 at 02:10 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: 05/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview], medication was observed to be stored in pill containers. The licensee did not comply with the section cited above in [5] out of [5] persons which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/20/2024
Plan of Correction
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Licensee states she will provide a refresher training on medication storage and management. Will provide a letter documenting the date, time and staff signatures of training completed.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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
LICENSING EVALUATOR NAME:Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2024


LIC809 (FAS) - (06/04)
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