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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880768
Report Date: 09/01/2022
Date Signed: 09/01/2022 04:50:01 PM

Document Has Been Signed on 09/01/2022 04:50 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
RIVERSIDE, CA 92507
FACILITY NAME:PINE CREEK CARE SERVICESFACILITY NUMBER:
331880768
ADMINISTRATOR:DAVIS, CHRISFACILITY TYPE:
735
ADDRESS:38203 PINE CREEK PLACETELEPHONE:
(951) 319-6374
CITY:MURRIETASTATE: CAZIP CODE:
92562
CAPACITY: 4CENSUS: DATE:
09/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Manager, Hoang TruongTIME COMPLETED:
04:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced visit to the facility for the purpose of annual inspection with focus on infection control. LPA met with facility manager, Hoang Truong, who was informed of the purpose of the visit.

LPA conducted a walk through of the interior and exterior of the facility. LPA observed resident bedrooms that would be used a isolation rooms.

LPA observed the following COVID-19 related violations:
  • Facility staff and residents were not wearing a mask
  • (3) out of (3) resident restrooms did not have hand soap
  • LPA was not screened when entering the facility and staff was not trained on how to screen visitors
  • Resident temperature checks were not being taken or recorded everyday.
  • Staff have not been N95 FIT tested
  • Facility lacked COVID-19 postings throughout the facility
These will be documented on LIC9102TV Technical Violation Form.

LPA along with facility manager observed the following deficiencies:
  • Identification and Emergency Information was not filled out for R1 who has been admitted to the facility for (3) months.
  • Resident restroom had unlocked cleaning supplies
  • Facility was not incompliance with the required (1) week supply of non-perishable food items

Deficiencies were documented on LIC809-D.


An exit interview was conducted where this report along with LIC809-D pages, LIC9102TV pages, and appeal rights were reviewed and provided to facility manager.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2022
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 10
Document Has Been Signed on 09/01/2022 04:50 PM - It Cannot Be Edited


Created By: Janira Arreola On 09/01/2022 at 04:09 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: PINE CREEK CARE SERVICES
FACILITY NUMBER: 331880768

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(b)(5)
(b) Each record must contain information including, but not limited to, the following:
(5) Names, addresses, and telephone numbers of the authorized representative.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above. LPA reviewed R1's file for emergency contact information. LPA inquired with staff if this had been updated. zLPA was told that the information was not on file since May 2022 when the staff was admitted. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/10/2022
Plan of Correction
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Administrator will submit completed Emergency and Identification form LIC601 for R1 by the POC date to LPA.
Type B
Section Cited
CCR
85076(d)(1)
(d) The licensee shall meet the following food supply and storage requirements:
(1) Supplies of staple nonperishable foods for a minimum of one week...shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation,interview, record review, the licensee did not comply with the section cited above with non-perishable food supply that was not in the required 1 week supply. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/10/2022
Plan of Correction
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Facility will obtain the required (1) week supply of non-perishable foods for the amount of residents in care for (3) meals a day by the POC date to LPA.
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: 09/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2022


LIC809 (FAS) - (06/04)
Page: 8 of 10
Document Has Been Signed on 09/01/2022 04:50 PM - It Cannot Be Edited


Created By: Janira Arreola On 09/01/2022 at 04:21 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: PINE CREEK CARE SERVICES
FACILITY NUMBER: 331880768

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(g)
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above due to unlocked cleaning supplies that were on bathroom counter of resident common restroom. This posesa potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/10/2022
Plan of Correction
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Facility will store cleaning supplies in designated locked cabinets and retrain staff on proper storage of chemicals. Proof of retraining will be submitted to LPA by POC date.
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:Joel Esquivel
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2022


LIC809 (FAS) - (06/04)
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