331881092-7-14-2023-18-AS-SMAZ-CTQV7T-20230714161141

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881092
Report Date: 07/14/2023
Date Signed: 07/14/2023 04:11:49 PM

Document Has Been Signed on 07/14/2023 04:11 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:	AM/PM ASSURED CARE, INC		FACILITY NUMBER:	331881092
ADMINISTRATOR:	AGUINALDO, PEARL ANNE		FACILITY TYPE:	740
ADDRESS:	30096 ALEXANDER DRIVE		TELEPHONE:	(760) 534-1351
CITY:	CATHEDRAL CITY	STATE: CA	ZIP CODE:	92234
CAPACITY:	6	CENSUS: 4	DATE:	07/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Russel Aguinaldo - Adminstrator		TIME COMPLETED:	04:30 PM

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Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit. LPA was granted entry and met with Administrator, Russel Aguinaldo, who was informed of the purpose of the visit. At the time of the visit there was three (3) staff and four (4) residents present.

The facility is a one-story home with five (5) bedrooms and four (4) bathrooms with attached garage, and pool in the backyard. The clients served are elderly adults 65 years of age and older. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted a staff and resident interviews. LPA observed the following:

Infection Control: The LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements. LPA reviewed staff records and found that all staff had infection control training.

Physical Plant: LPA observed the resident bedrooms and staff office. 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 the facility pool was surrounded by a locked gate. LPA observed outdoor furniture and shaded area for clients. Due to weather conditions the administrator is currently in the process of installing new shade covers for the residents. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to clients. The smoke detector and carbon monoxide was operational, and the hot water temperature 115.7 F.

Food Service: LPA observed 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.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Sara Martinez	TELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

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: AM/PM ASSURED CARE, INC	FACILITY NUMBER: 331881092
	VISIT DATE: 07/14/2023

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Care & Supervision/Administration: Adequate staff are present for the supervision of residents during the visit. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The listed administrator possesses a current administrator's certificate.

Record Review and Resident/Staff Files: LPA reviewed three (3) staff files and training. All staff have criminal clearance and updated training along with CPR/First Aid Certification. Two (2) resident files were reviewed and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: LPA observed resident medication cabinet unlocked during the time of the vist. LPA brought it to the administrators attention and he corrected the issue and informed his staff to keep the medication cabinet locked. A deficiency will be issued. LPA reviewed medications for two (2) residents and found all medication listed on MARS and all required labeling was found to be in place.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. Based on interview, Administrator stated they have not performed a earthquake and fire drill in the past year which does not meet title 22 regulations. A deficiency will be issued and a plan of correction. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies in the garage and first aid kit with all required items.

An exit interview was conducted where a copy of this report, LIC809D, appeal rights was provided to Administrator, Russel Aguinaldo.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Sara Martinez	TELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/14/2023 04:11 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: AM/PM ASSURED CARE, INC	FACILITY NUMBER: 331881092
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(2)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in ensuring the medication cabinet is locked and inaccessible to the residents during the time of visit which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/21/2023
	Plan of Correction
1 2 3 4	Licensee immediately corrected the issue when told and informed the staff present to make sure the medication cabinet. Licensee will review the regulations and submit a statement that the regulation is understood to LPA by POC date. Licensee further states that training will be conducted to all staff regarding the use of locks and submit proof of such to LPA by POC date via email.

Type B

Section Cited

CCR

87705(l)(8)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in conducting a fire/earthquake drill based off the deparment's requirments when caring for residents with dementia. The last time a fire/earthquake drill was conducted was last year which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/21/2023
	Plan of Correction
1 2 3 4	The Licensee will ensure fire and earthquake drills will be conducted and logged quartely every year by the administer and will provide a statement as proof of staff training on Title 22 regulations on proper fire and earthquake drills. Proof will be submitted by the Department by the agreed POC due 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.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Sara Martinez	TELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

LIC809 (FAS) - (06/04)

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