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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880725
Report Date: 01/26/2023
Date Signed: 01/26/2023 11:18:47 AM


Document Has Been Signed on 01/26/2023 11:18 AM - 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: 3DATE:
01/26/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:24 AM
MET WITH:Licensee, Esta HobbsTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola conducted a health and safety visit to the facility on 1/26/2023 at 9:24 a.m. LPA met with Licensee, Esta Hobbs who was informed of the purpose of the purpose of the visit. At the time of the visit there were (2) staff and (3) residents present.

The department had gotten a cross-report for suspected elder abuse for R1 on 01/12/2023, where it was written that R1 was handled in a rough manner at the facility by an outside agency. LPA spoke with R1 during the time of the visit who stated they were "absolutely fine". LPA observed the R1's neck and clavicle area and did not observe any signs of rough handling. LPA collected the body check done on R1 from the time of the incident to today's date, which did not include any signs of deterioration in the skin integrity.

LPA spoke with the licensee who stated that the incident had been reported and faxed to the department on 1/25/2023. LPA was informed by the regional office that these reports were received. Through conversation licensee expressed agreement and understanding of the reporting requirements for suspected elder abuse. The licensee acknowledges that an incident report must be sent to the department and SOC341 to the appropriate agencies.

It was found that R1 has a camera with monitor in their room that the facility does not have an exception on file for. Licensee stated they will submit a exception request for the camera monitor. LPA documented deficiency and plan of correction for this.

An exit interview was conducted and copy of this report was reviewed and provided to Licensee, Esta Hobbs, along with LIC 809-D page and appeal rights.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 01/26/2023 11:18 AM - 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: TEMPLE HEIGHTS
FACILITY NUMBER: 331880725

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/27/2023
Section Cited

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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1)To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirment was not met as evidenced by:
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The licensee stated they would send an exception for R1's bedroom camera. The exception will include the use for the camera, where the monitor will be placed, who will view the monitor. This shall be submitted by the POC due date to the LPA.
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Based on observation and interview it was found that R1 has a monitoring camera in their room with display feed that is visable to staff. Based on interview it was found that the licensee does not have an exception for this. This poses an immediate personal rights, health or saftey risk to R1.
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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: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2