331880905-9-19-2023-18-AS-CGOH-CVTUZX-20230919160215

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880905
Report Date: 09/19/2023
Date Signed: 09/19/2023 04:02:19 PM

Document Has Been Signed on 09/19/2023 04:02 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	TEMECULA MEMORY CARE		FACILITY NUMBER:	331880905
ADMINISTRATOR:	GEDDIE, JAMES		FACILITY TYPE:	740
ADDRESS:	44320 CAMPANULA WAY		TELEPHONE:	(951) 428-4990
CITY:	TEMECULA	STATE: CA	ZIP CODE:	92592
CAPACITY:	64	CENSUS: 46	DATE:	09/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:21 PM
MET WITH:	Clinical Care Coordinator, Azizi Baranaukas		TIME COMPLETED:	04:03 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) Cheryl Goodrich arrived at 2:21 p.m. to conduct an unannounced annual visit. LPA met Clinical Care Coordinator, Azizi Baranaukas. The purpose of today’s visit is to inspect the facility to ensure that the facility is following California Code of Regulations, Title 22, Division 6. Facility is approved for 64 ambulatory and non-ambulatory residents. The facility has 46 residents in care. Infection Control Plan: The facility has an approved infection control plan and a surplus of supplies for infection control including but not limited to mask, gloves, gowns, first aid kit, and cleaning supplies. Physical Plant and Environmental Safety: The facility temperature read at 72 degrees. The facility consists of 32 resident bedrooms, and 36 bathrooms, living room, kitchen, patio, and activities room. The bedrooms are furnished with lighting, closet space, and dresser. The beds are clean and have clean linens and the pathways are clean and clear of obstruction. The living room and kitchen are clean and clear of obstruction. The medications are stored in a locked medication carts, and in the med room inaccessible to residents. The facility has a current fire clearance, smoke and carbon monoxide detectors and fire extinguishers and are in working order. Personnel Records-Training: The staff records are completed with fingerprint clearance, Health screening for TB, CPR/First Aid training, and in-service trainings. Client Records-Incident Reports: The facility has identification and emergency information, physician’s report, resident appraisal, hospice documentation, additional assessments, client rights, and admissions agreements. (Continued on LIC809-C)

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Cheryl Goodrich	TELEPHONE: 951-248-0308
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

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

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: TEMECULA MEMORY CARE	FACILITY NUMBER: 331880905
	VISIT DATE: 09/19/2023

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
26
27
28
29
30
31
32

(Continued from LIC809)

Client Rights-Information: The facility has client rights information posted in the facility.
Food Service: The facility has a food service delivery which comes daily for breakfast, lunch, and dinner.
Health- Related Services: The facility has an electronic medication logbookand the documents the resident’s medication and in compliance with physician’s orders and regulations.
Disaster Preparedness: The facility has a disaster plan and has posted the evacuation plan, visible for staff and residents in care. The last fire drill was completed 08/20/23. The facility has emergency supply of food and water.
Summary: Based on today's visit, no deficiencies were observed at this time. An exit interview was conducted with Clinical Care Coordinator, Azizi Baranaukas. and a copy of this report was printed Signature below confirms receipt of these rights.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Cheryl Goodrich	TELEPHONE: 951-248-0308
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2