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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881006
Report Date: 01/25/2024
Date Signed: 01/25/2024 02:21:24 PM


Document Has Been Signed on 01/25/2024 02:21 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:CONCORD ESTATES ASSISTED LIVINGFACILITY NUMBER:
331881006
ADMINISTRATOR:RAMIREZ, HEATHERFACILITY TYPE:
740
ADDRESS:31565 FLINTRIDGE WAYTELEPHONE:
(619) 251-8508
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY:6CENSUS: 5DATE:
01/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:48 AM
MET WITH:Heather Ramirez, LicenseeTIME COMPLETED:
02:30 PM
NARRATIVE
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On 1/25/2024, Licensing Program Analyst (LPA) Chinwe Nwogene arrived unannounced at the facility to conduct an annual inspection. LPA Nwogene was greeted and granted entry by Caregiver, Mia Ibarra who was informed of the purpose of the visit. LPA also met with Licensee, Heather Ramirez who was informed of the purpose of visit. At the time of visit there was two #2 staff and five #5 residents present. LPA toured the facility inside and out with Caregivers, Samantha Vasquez and Mia Ibarra, and Heather Ramirez.

Tour included:

Kitchen: LPA toured the kitchen and observed the kitchen to be clean. Food is stored in a safe and healthful manner. Utensils and dishware are sufficient for the capacity. The refrigerator and stove are in working order. Trash cans has tight-fitting lid. Fridge, freezer, and all need appliances were present and shown to be in working condition and clean. During LPA’s tour of the kitchen, LPA observed the knives and other sharps in the kitchen drawer not locked, accessible to clients. LPA asked Mia and Samantha to lock the drawer but was told they couldn’t find the key and the knives are not usually locked. Heather arrived and immediately locked the drawer (Citation will be issued).

Dining and Livingroom; LPA toured the dinning and Livingroom area. LPA observed area to be clean and furnitures in good condition. Temperature was 72 degrees Fahrenheit.



Hallway: LPA toured the hallway and observed hallway to be clean with no pathway obstruction. LPA inspected the fire extinguisher and found it to be in compliance and record to be up to date. Carbon monoxide & smoke detector were tested and functioning properly. LPA observed additional linens and hygiene items.

Medication: Medications were labeled and stored in separate bins inside of a locked medication cart and are distributed according to physician orders. The first aid kit was complete.

SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Chinwe NwogeneTELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2024
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 4


Document Has Been Signed on 01/25/2024 02:21 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: CONCORD ESTATES ASSISTED LIVING
FACILITY NUMBER: 331881006

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Disregard
POC Due Date: 02/02/2024
Plan of Correction
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Disregard
Type B
Section Cited
CCR
87309(a)(1)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having knives, other sharps and cleaning solutions not locked making it accessible for the residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/02/2024
Plan of Correction
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Licensee immediately locked up the knivies and sharps, making it inaccessible to clients.
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: Rikesha StampsTELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Chinwe NwogeneTELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/25/2024 02:21 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: CONCORD ESTATES ASSISTED LIVING
FACILITY NUMBER: 331881006

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(f)
Personnel Records
(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by not having staff files available for review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/02/2024
Plan of Correction
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Licensee stated proof of staff file will be provided to LPA by the POC due date 2/2/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Rikesha StampsTELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Chinwe NwogeneTELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


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: CONCORD ESTATES ASSISTED LIVING
FACILITY NUMBER: 331881006
VISIT DATE: 01/25/2024
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Bathroom: LPA toured three #3 resident bathrooms and observed bathrooms to be clean and equipped with grab bar and non-slip mat. There is also a good number of personal toiletries available for the residents in care. The hot water measured at 113 degrees Fahrenheit.

Bedroom: LPA toured six #6 out of #6 resident bedrooms and observed bedrooms to be clean and furnished according to regulation, which includes proper furniture, dressers, chairs, and lighting. Night lights were maintained throughout the facility.

Garage: LPA tour the garage and observed garage to be clean.

Laundry: Washing machine and dryer are all in good repair and sufficient for the census. Cleaning supplies are stored away in the laundry room. During LPA’s toured of the laundry room, LPA observed laundry room to be open and cleaning solutions not locked up in the laundry room making it accessible to clients (Citation will be issued).

Backyard: LPA toured the backyard and observed backyard to be clean and furnitures in good condition. The backyard was free from obstruction and the side gate remain unlocked. No bodies of water were observed.

Food Services: There are seven days non-perishable and two days of perishable food supply present, and all food was properly stored and available to residents. Fridge and Freezer are large enough to accommodate required perishable foods.

Records: All required postings, including COVID’s postings, were posted near the entryway and throughout the facility. The administrator certificate expires on 2/12/2024. Three #3 residents file were reviewed. LPA requested for three staff files for review but was informed by Heather that staff files are not available at the facility (Citation will be issued).

Interview: Two staff and three residents were interviewed.

Therefore, based on the observations made during today’s visit, three #3 deficiencies will be cited per Title 22, Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted, and this reported was provided along with appeal rights to Heather Ramirez.

SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Chinwe NwogeneTELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024
LIC809 (FAS) - (06/04)
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