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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880815
Report Date: 02/22/2023
Date Signed: 02/22/2023 01:49:54 PM


Document Has Been Signed on 02/22/2023 01:49 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: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:
02/22/2023
TYPE OF VISIT:Case Management - DeficienciesANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Licensee/Administrator Florence MojicaTIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Melody Brown met with Licensee/Administrator Florence Mojica at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office 02/22/2023 at 12:20 PM to initiate a Case Management Office Visit. LPA Brown explained the purpose of the requested Office Visit. The investigation consisted of interviews and a review of pertinent documentation.

LPA Brown reviewed documents and interviewed staffs and it indicated that R1 does not have Pre-Admission Appraisal. The Licensee failed to interview R1 and R1's responsible person for facility admissions. LPA Brown will issue a citation for this issue as this pose potential health, safety and personal rights risks to resident in care.

In addition, LPA Brown observed that R1 only have one (1) LIC602A Physician Report with physician signature date 12/24/2019 and the facility failed to conduct R1's medical assessment annually to reassess R1's dementia care needs. Moreover, LPA Brown also observed that no reappraisal was done by the Licensee annually for R1 to reassess R1's dementia care needs. LPA Brown will issue a citation for this issue as this pose immediate health, safety and personal rights risks to resident in care.

An exit interview was conducted where this report (LIC809), LIC809D, 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: 02/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2023
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 02/22/2023 01:49 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: A TENDER TOUCH SENIOR LIVING LLC
FACILITY NUMBER: 331880815

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/23/2023
Section Cited

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87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible... (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a
reappraisal done at least annually...This requirement is not met as evidenced by:
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Licensee stated to submit signed Statement of Understanding on CCR 87705(c)(5) 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 having
annual medical assessment and a reappraisal done at least annually for R1 which pose immediate health, safety and personal rights risk to resident in care.
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Type B
03/01/2023
Section Cited

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87457 Pre-Admission Appraisal – General (a) Prior to admission, the prospective resident and his/her responsible person, if any, shall be interviewed by the licensee or the employee responsible for facility admissions. This requirement is not met as evidenced by:

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Licensee stated to submit signed Statement of Understanding on CCR 87457(a) 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 having a completed Pre-Admission Appraisal for R1 which 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: 02/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2023
LIC809 (FAS) - (06/04)
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