331880838-12-6-2024-56-AS-JPRO-DBPT4P-20241206132417

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880838
Report Date: 12/06/2024
Date Signed: 12/06/2024 01:24:25 PM

Document Has Been Signed on 12/06/2024 01:24 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:	EMK RESIDENTIAL CARE FOR ELDERLY		FACILITY NUMBER:	331880838
ADMINISTRATOR/ DIRECTOR:	PANALIGAN, MARILOU		FACILITY TYPE:	740
ADDRESS:	7750 BOLERO DRIVE		TELEPHONE:	(951) 332-0558
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92509
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	12/06/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:40 AM
MET WITH:	Monico Panaligan, Administrator		TIME VISIT/ INSPECTION COMPLETED:	01:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Javier Prieto made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection LPA met with Monico Panaligan, administrator and was granted entry to the facility. At the time of the visit there was three (3) staff present, and three (3) residents were present. The facility is a four (4) bedroom, three (3), bathroom home, with a kitchen/dining area, living room, and detached garage. Licensed capacity is (6) current census (6). LPA was accompanied by licensee Panaligan, to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperatures in the bathrooms to be in compliance. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Alarms were tested and found to be in working order. Water temperature measured 125.5 degrees at today's inspection. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. There was a designated storage space for client/staff files. Medications are kept inside lock box inaccessible to clients. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care

Karen Clemons	TELEPHONE: (951) 248-0349
Javier Prieto	TELEPHONE: 951-217-3135
	DATE: 12/06/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024

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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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: EMK RESIDENTIAL CARE FOR ELDERLY	FACILITY NUMBER: 331880838
	VISIT DATE: 12/06/2024

NARRATIVE

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Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department

Record Review: LPA reviewed six (6) resident's records. Resident #1 (R1) did not have a Physician's Report with a negative TB result during time of inspection.

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

An exit interview was conducted, and this report (LIC 809, LIC 809D and appeal rights) were discussed and provided to Mr Panaligan and a copy was left with the facility.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/06/2024 01:24 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: EMK RESIDENTIAL CARE FOR ELDERLY	FACILITY NUMBER: 331880838
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Medical Assessment

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in count 1out of 6 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/13/2024
	Plan of Correction
1 2 3 4	Administrator to submit completed Physician's Report to LPA, via email, for resident #1 by POC date.

Section Cited

Medical Assessment

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in count 1 of 6 persons, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/13/2024
	Plan of Correction
1 2 3 4	Administrator to submit completed negative TB results to LPA, via email, for resident #1 by POC date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Karen Clemons	TELEPHONE: (951) 248-0349
Javier Prieto	TELEPHONE: 951-217-3135
	DATE: 12/06/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/06/2024 01:24 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: EMK RESIDENTIAL CARE FOR ELDERLY	FACILITY NUMBER: 331880838
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

This requirement is not met as evidenced by: During today's inspection, water temperature read 125.5 F.
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/13/2024
	Plan of Correction
1 2 3 4	Administrator to submit reading of water temperature to read between 105 and 120 degrees F by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Karen Clemons	TELEPHONE: (951) 248-0349
Javier Prieto	TELEPHONE: 951-217-3135
	DATE: 12/06/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024

LIC809 (FAS) - (06/04)

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