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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880898
Report Date: 04/18/2024
Date Signed: 04/18/2024 04:24:18 PM


Document Has Been Signed on 04/18/2024 04:24 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:HELPING HANDS CARE HOMESFACILITY NUMBER:
331880898
ADMINISTRATOR:KINCHERLOW, TYLAFACILITY TYPE:
740
ADDRESS:33999 TUSCAN CREEK WAYTELEPHONE:
(951) 365-0443
CITY:TEMECULASTATE: CAZIP CODE:
92592
CAPACITY:5CENSUS: 5DATE:
04/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:11 PM
MET WITH:Tyla Kincherlow - LicenseeTIME COMPLETED:
04:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit . LPA was granted entry and met with Licensee Tyla Kincherlow, who was informed of the purpose of the visit. At the time of the visit there was one (1) staff and five (5) residents present. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following:

Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. LPA observed outdoor furniture and shaded area for residents. LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. Facility contained PPE equipment and cleaning supplies to do regular cleaning of the facility. Cleaning supplies and detergents were locked and inaccessible to residents. The sharp and dangerous objects was locked and inaccessible to residents. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The smoke detector and carbon monoxide was operational, and the hot water temperature was recorded at 108 degree F, which met department requirements. Facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.



LPA reviewed staff files and training. All staff have the required personnel records on file and criminal record clearance and updated training along with CPR/First Aid Certification. Four (4) resident files were reviewed. Record review of resident files revealed R1 and R2 did not have a Physician's Report available for review. A deficiency cited under Title 22 Regulation 87458(a) Medical Assessment.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 605-0913
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2024
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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: HELPING HANDS CARE HOMES
FACILITY NUMBER: 331880898
VISIT DATE: 04/18/2024
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LPA observed the centrally stored medication cabinet to be locked and inaccessible to residents in care. LPA reviewed medications for four (4) residents and found medication listed on medication list was found to be in place. LPA reviewed medication and observed PRN for R2 was not being documented when administered. A deficiency cited under Title 22 Regulation 87465(d)(3) Incidental Medical and Dental will be issued along with a plan of correction.

LPA reviewed the facility's emergency and disaster plan. A technical assistance (TA) will be issued under Healthy and Safety Code 1569.695(c) due to quarterly fire drill required to be conducted by the end of the April 2024. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies in the garage and first aid kit with all required items. Fire extinguishers were fully charged and inspected.

An exit interview was conducted where a copy of this report, LIC 809-D, and appeal rights was provided to Tyla.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 605-0913
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 04/18/2024 04:24 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: HELPING HANDS CARE HOMES
FACILITY NUMBER: 331880898

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(d)(3)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 4 resident PRN medication not being documented and maintained which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/26/2024
Plan of Correction
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Licensee will ensure PRN medication dosage recording keeping will be updated and maintained on a regular basis. Licensee will provide training to staff on proper record-keeping of medications given and will provide proof of training to the Department by POC date of 4/26/2024.
Type B
Section Cited
CCR
87458(a)
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
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Based on interviews and record review, the licensee did not comply with the section cited above in 2 of 4 residents (R1) and (R2), which poses a potential health risk to persons in care. LPA observed R1 has been in the facility since November 2023 and R2 has been in the facility since February 2023, the facility does not have a Physician's Report on file for R1 and R2.
POC Due Date: 04/26/2024
Plan of Correction
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Licensee agrees to make plan for obtaining a Physician's Report for R1 and R2 as soon as possible. Licensee will reach out to resident's responsible party(s) immediately to start the process to obtain Physician's Report. Licensee to provide LPA with R1 and R2's Physician's Report by Plan of Correction date of 4/26/24.
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: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 605-0913
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2024
LIC809 (FAS) - (06/04)
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