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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881154
Report Date: 02/23/2024
Date Signed: 02/23/2024 11:07:32 AM


Document Has Been Signed on 02/23/2024 11:07 AM - 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:HOME OF PURPOSE LLCFACILITY NUMBER:
331881154
ADMINISTRATOR:LEGASPI, ALYSSA GRACEFACILITY TYPE:
740
ADDRESS:37544 RIVER OATS LANETELEPHONE:
(858) 231-5710
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY:4CENSUS: 2DATE:
02/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Staff, Eduardo RomeroTIME COMPLETED:
11:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola conducted a required annual visit. LPA met with Staff, Eduardo Romero, who was informed of the purpose of the visit. The licensee was available over the phone during the visit. At time of visit there were (2) clients and (2) staff present.

The facility is a two story home, with licensed rooms down stairs with (2) bedrooms and (1) bathrooms. The home has an attached garage, and no fire arms. The home has a pool surrounded by a locked gate. The facility is a residential care facility for the elderly serving elderly ages 60 and above. LPA observed the following:

Infection Control: LPA observed hand hygiene supplies, PPE equipment and cleaning supplies to do regular cleaning of the facility. The facility has a infection control plan on file and staff training.

Physical Plant: Physical plant, floors, windows, and doors were observed to be clean and fixtures and furniture were present and in good repair. The facility's outdoor area was observed to be free of hazards. Laundry equipment was observed to be in good working condition. The carbon monoxide detector was tested and operational during the visit.

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 food items.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2024
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: HOME OF PURPOSE LLC
FACILITY NUMBER: 331881154
VISIT DATE: 02/23/2024
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Record Review and Resident/Staff Files: LPA reviewed staff files and training along with CPR/First Aid. Client files were reviewed and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: All client medication was locked in lock boxes. LPA reviewed client medications and found that MARS and medication was accounted for and had required labeling.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing last fire drill conducted on September 2023. The facility was cited and plan of correction was created with licensee over the phone.

An exit interview was conducted where a copy of this report, along with LIC809-D page, appeal rights and LIC9098 were reviewed and provided to, Staff, Eduardo Romero and Licensee, Jason Legaspi over the phone.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/23/2024 11:07 AM - 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: HOME OF PURPOSE LLC

FACILITY NUMBER: 331881154

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 02/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above with documentation of last drill that did not comply with the requirment which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/29/2024
Plan of Correction
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The licensee agreed to send the LPA documentation of a drill conducted by the POC due date. Documentation requirments described in the section cited above should be adhered to.
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: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2024
LIC809 (FAS) - (06/04)
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