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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880763
Report Date: 08/11/2022
Date Signed: 08/11/2022 02:50:11 PM


Document Has Been Signed on 08/11/2022 02:50 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
, CA 92507



FACILITY NAME:NEW HOPE RESIDENTIAL ELDER CARE IIIFACILITY NUMBER:
331880763
ADMINISTRATOR:MIKENAS, ANNIE JANE ZFACILITY TYPE:
740
ADDRESS:36040 PEPPERDINE COURTTELEPHONE:
(951) 599-4585
CITY:WINCHESTERSTATE: CAZIP CODE:
92596
CAPACITY:6CENSUS: 6DATE:
08/11/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Ralp Abano- CaregiverTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to the facility. The purpose of the visit was to conduct a case management visit. LPA met with Caregiver Ralp Abano and was granted entry to the facility. At the time of visit there were two (2) staff, and five (5) residents present.

LPA Gardner toured the facility inside and out checking on food supply, medications, physical plant, and the residents in care.

During today’s visit, LPA found that a staff member is sleeping and residing in a resident’s bedroom closet. Within the bedroom closet the staff member had personal belongings, a bed, and a dresser. The staff member sleeping and residing in residents bedroom closet poses a potential health, safety, or personal rights risk to persons in care.

During today’s visit, LPA also found that resident’s medications are being stored in containers that are not the original prescription bottles which poses an immediate health, safety, or personal rights risk to persons in care.

Based on the observations made during today’s visit, two (2) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report was discussed and provided to Caregiver Ralp Abano, along with a copy of the LIC-809D form, and a copy of the appeal rights.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2022
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 08/11/2022 02:50 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
, CA 92507


FACILITY NAME: NEW HOPE RESIDENTIAL ELDER CARE III
FACILITY NUMBER: 331880763

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/12/2022
Section Cited

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87465. Incidental Medical and Dental Care.(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.
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This requirement is not met as evidenced by observation, the licensee did not comply with the section cited above by storing resident's medications in containers that are not the original prescription bottles from the pharmacy which poses an immediate health, safety or personal rights risk to persons in care.
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Type B
08/14/2022
Section Cited

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87307. Personal Accommodations and Services.(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility...
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This requirement is not met as evidenced by observation, the licensee did not comply with the section cited above by allowing a staff member to reside and sleep in a residents bedroom closet which poses an potential health, safety or personal rights risk to persons in care.
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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: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2