331881076-9-20-2023-18-AS-JROO-CVURZN-20230920132814

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881076
Report Date: 09/20/2023
Date Signed: 09/20/2023 01:28:19 PM

Document Has Been Signed on 09/20/2023 01:28 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:	MORNING GLORY HOME		FACILITY NUMBER:	331881076
ADMINISTRATOR:	BUENSUCESO, ESTRELLA		FACILITY TYPE:	735
ADDRESS:	24533 MORNING GLORY ST.		TELEPHONE:	(909) 789-8980
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92553
CAPACITY: 4		CENSUS: 2	DATE:	09/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:35 AM
MET WITH:	Licensee, Estrella Buensuceso		TIME COMPLETED:	01:30 PM

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On 9/20/2023, Licensing Program Analyst (LPA) Janette Romero arrived unannounced at the facility to conduct an annual required visit. LPA met with Licensee Estrella Buensuceso. During the visit, there was two (2) staff and two (2) clients present.

The facility is approved to care for four (4) ambulatory clients and serves adults ages 18-59. LPA toured the facility with House Manager, Edwin Encisa. During the visit, LPA observed the following:

Kitchen: LPA toured the kitchen and observed kitchen to be clean. Food is stored in a safe and healthful manner. The facility has a 2-day supply of perishable food items and 7-day of non-perishable food items. Knives and cleaning solutions are stored in kitchen cabinets that are secured with a master lock.

Dining and Living room: LPA toured the dining and living/family room area. LPA observed area to be clean and furniture in good condition. Activities and board games are available for clients. Fire extinguisher is charged and mounted near the dining room.

Hallway: LPA toured the hallway and observed hallway to be clean with no pathway obstruction. Carbon monoxide and smoke detector were tested and functioning properly.

Records: Staff present have a criminal record clearance on file and current CPR/First Aid certification.

Continued on LIC809-C..

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023

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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MORNING GLORY HOME	FACILITY NUMBER: 331881076
	VISIT DATE: 09/20/2023

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Continued from LIC809.

Centrally Stored Medications: LPA observed two (2) first aid kits with required components. Medications were secured in a cabinet near the living room. LPA reviewed physical medications for both clients as well as the Medication Administration Record (MAR) used to log administration of clients’ medications. LPA observed that facility staff used white-out to make corrections on the MAR on three (3) occasions. Deficiency cited.

Bedrooms: Client bedrooms were each furnished with a bed, chair, closet, clothing storage and lighting.

Bathrooms: Bathrooms have a working toilet, wash basin, and were equipped with a nonskid mat in the shower. The hot water temperature in the client bathrooms measured at 114- and 120-degrees Fahrenheit. The facility has clean towels, blankets, and linen, available in different colors for the clients in care.

Laundry/Garage: Washing machine and dryer are in good repair. Emergency food, water, PPE, and incontinent supplies are stored in the garage.

Yard/Outside Area: A brick wall secured the entire backyard. All outdoor pathways were free of obstructions. No bodies of water were observed. There were no firearms or ammunition observed at the facility, and LPA was informed the facility will not store firearms or ammunition on the premises.

During today's visit, LPA observed one (1) deficiency faulting the facility. An exit interview was conducted, and a copy of this report was reviewed and provided to Licensee Buensuceso along with a LIC809-D and Appeal Rights.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/20/2023 01:28 PM - It Cannot Be Edited

Created By: Janette Romero On 09/20/2023 at 01:14 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: MORNING GLORY HOME	FACILITY NUMBER: 331881076
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80075(b)

80075 Health Related Services (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interview, the licensee did not comply with the section cited above due to record review revealing that facility staff made corrections to the clients' Medication Administration Record using white-out, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/29/2023
	Plan of Correction
1 2 3 4	Licensee agreed to provide staff training regarding medication management and proper documentation. Proof of correction to be submitted to LPA by close of business on POC due 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.

SUPERVISOR'S NAME:

Joel Esquivel

LICENSING EVALUATOR NAME:

Janette Romero

LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023

LIC809 (FAS) - (06/04)

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