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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880815
Report Date: 12/21/2022
Date Signed: 12/21/2022 11:01:32 AM


Document Has Been Signed on 12/21/2022 11:01 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
, CA 92507



FACILITY NAME:A TENDER TOUCH SENIOR LIVING LLCFACILITY NUMBER:
331880815
ADMINISTRATOR:MOJICA, FLORENCE AFACILITY TYPE:
740
ADDRESS:1651 ROSE AVENUETELEPHONE:
(310) 592-5338
CITY:BEAUMONTSTATE: CAZIP CODE:
92223
CAPACITY:6CENSUS: 3DATE:
12/21/2022
TYPE OF VISIT:Case Management - DeficienciesANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Licensee/Administrator Florence MojicaTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Melody Brown and MIchelle Echeverria met with Licensee/Administrator Florence Mojica at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office 12/21/2022 at 10:00 AM to initiate a Case Management Office Visit. LPAs Brown and Echeverria explained the purpose of the requested Office Visit. The investigation consisted of observation, interviews and a review of pertinent documentation.

During the facility visit last 12/21/2021 at 12:30 PM and per documents review, LPAs Brown and Lama did not find any Special Incident Report (SIR) that the facility submitted to Community Care Licensing Division (CCLD) to report that R3 had a wound on right arm while hospice staff is giving R3 a shower. LPA Brown will issue a citation for not reporting the incident at the facility to CCLD as this pose potential health, safety and personal rights risk to resident in care.

An exit interview was conducted where this report (LIC809), LIC80D, and Appeal Rights were discussed and provided to Licensee/Administrator Florence Mojica.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2022
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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Document Has Been Signed on 12/21/2022 11:01 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
, CA 92507


FACILITY NAME: A TENDER TOUCH SENIOR LIVING LLC
FACILITY NUMBER: 331880815

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/03/2023
Section Cited

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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require... (1) A written report shall be submitted to the licensing agency... This requirement is not met as evidenced by:
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Licensee stated to train all staff on CCR 87211(a)(1) and submit proof of Staff Training Log to LPA Brown by POC due date.
Licensee will submit Signed Statement of Understanding on CCR 87211(a)(1) to LPA Brown by POC due date.

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Based on interview and records review, the Licensee did not comply with the section cited above by not submitting Special Incident Report (SIR) that R3 had a wound on right arm while hospice staff is giving R3 a shower. This pose potential health, safety and personal rights risk to resident 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: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2022
LIC809 (FAS) - (06/04)
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