331881092-7-24-2024-18-AS-SJEN-D7H22E-20240724170038

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881092
Report Date: 07/24/2024
Date Signed: 07/24/2024 05:00:50 PM

Document Has Been Signed on 07/24/2024 05:00 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:	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:	07/24/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Russell Aguinaldo, administrator		TIME COMPLETED:	05:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Seo Jeon and Licensing Program Manager(LPM) Rikesha Stamps conducted an unannounced annual required visit. LPA was granted entry and met with administrator, Russell Aguinaldo, who was informed of the purpose of the visit. At the time of the visit there were two(2) staffs and four(4) clients present.

The facility is a single story home with 5 bedrooms and 4 bathrooms with attached garage. There is fenced pool with locked gate on the premises and no firearms or other dangerous weapons are stored at the facility. The clients served are 60 and up. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted staff and client interviews.

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.

LPA observed the client 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 outdoor furniture and shaded area for clients. 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 and carbon monoxide detectors were operational, and the hot water temperature was 125.6 degrees F. There will be a citation for the water temperature. Fire extinguisher located in the kitchen area has current inspection tag.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Seo Jeon	TELEPHONE: 951-248-0309
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024

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: AM/PM ASSURED CARE, INC	FACILITY NUMBER: 331881092
	VISIT DATE: 07/24/2024

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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.

Adequate staff are present for the supervision of clients during the visit. LPA also reviewed the staff scheduled showing adequate staff coverage. 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.

LPA reviewed 6 staff files and training. All staff have criminal clearance and updated training along with CPR/First Aid Certification. 2 residents' files were reviewed and possessed all required paperwork.

All client medication was locked in a cabinet located in the dining room. LPA reviewed medications for four(4) clients and found all medication listed on MARs and all required labeling was found to be in place. LPA found medication records discrepancies in two(2) residents. There will be a citation.

LPA observed that staffs do not have required training for hoyer lift for R2. There will be a citation for lack of hoyer lift training.

LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing the facility performs monthly fire and earthquake drills, which met the department requirements. 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, deficiencies were issued, a copy of this report and appeal rights were provided to administrator, Russell Aguinaldo.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Seo Jeon	TELEPHONE: 951-248-0309
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/24/2024 05:00 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: AM/PM ASSURED CARE, INC	FACILITY NUMBER: 331881092
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above for 4 of 4 residents (R1, 2, 3 & 4). Faciity water temperature measured at 125.7 F degrees which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/25/2024
	Plan of Correction
1 2 3 4	Administrator agrees to conduct a water temperature check over the next 24 hours, in addition to documenting the results. Administrator will submit a photo of the new water temperture reading within the required and the documented results via email to LPA by POC due date 7/25/24 by 5pm.

Type A

Section Cited

CCR

87465(a)(2)

Incidental Medical and Dental Care Services

(2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above for 2 of 4 residents, a review of residents medication records revealed residents were not receiving their daily dosage per medication written perscription which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/02/2024
	Plan of Correction
1 2 3 4	Administrator agrees to review title 22 regulations Incidential Medical and Dental Care Services and submit a written letter to LPA indicating such. In addition all staff will receive training on medications by a licensed professional, proof of training will be submitted to LPA upon completion.

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 Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Seo Jeon	TELEPHONE: 951-248-0309
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 07/24/2024 05:00 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: AM/PM ASSURED CARE, INC	FACILITY NUMBER: 331881092
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87613(a)(2)

Prior to admission of a resident with a restricted health condition, Licensee shall ensure that facility staff who will participate in meeting the resident's specialized care needs complete training provided by a licensed professional sufficient to meet those needs. 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 for 1 of 4 residents (R2), R2 requires assistance with transferring to and from the bed. Staff utilizes a hoyer lift to assist R2, staff have not received the required training per the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/02/2024
	Plan of Correction
1 2 3 4	Administrator agrees to have all staff complete the required training in reference to proper use of the hoyer lift. Such training shall be administered by a licensed skilled professional. Administrator agrees to submit proof of training on the POC due date 8/2/24.

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: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Seo Jeon	TELEPHONE: 951-248-0309
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024

LIC809 (FAS) - (06/04)

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