331881166-8-28-2023-18-AS-JROO-CV5T8A-20230828143001

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881166
Report Date: 08/28/2023
Date Signed: 08/28/2023 02:30:10 PM

Document Has Been Signed on 08/28/2023 02:30 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:	TRANQUILITY VALLEY ASSISTED LIVING		FACILITY NUMBER:	331881166
ADMINISTRATOR:	FUENTES, TERESA		FACILITY TYPE:	740
ADDRESS:	26450 HELENE DRIVE		TELEPHONE:	(951) 807-3397
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92555
CAPACITY:	6	CENSUS: 6	DATE:	08/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Caregiver Soledad Camalig		TIME COMPLETED:	02:45 PM

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On 8/28/2023, Licensing Program Analyst (LPA) Janette Romero arrived unannounced at the facility to conduct an annual required visit. LPA was greeted and granted entry by Caregiver Soledad Camalig who was informed of the purpose of visit. During the visit, there was three (3) residents and two (2) staff present. LPA was informed three (3) residents were at day program.

The facility is approved to care for six (6) non-ambulatory residents and has a hospice waiver for six (6). The facility is made up of four (4) resident bedrooms, two (2) resident bathrooms, a kitchen, dining room, living/family area, laundry room and garage.

During the visit, LPA observed the following:

Kitchen: LPA observed kitchen to be clean. Food is stored in a safe and healthful manner. Sharps are secured in a locked kitchen drawer. The facility has a 2-day supply of perishable food items and 7-day supply of non-perishable food items.

Dining and Living room: LPA toured the dining and living/family room area. LPA observed areas to be clean and furniture in good condition. LPA observed residents resting in the living room and sleeping in their rooms. Fire extinguisher is charged and mounted in the dining room.

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

Continued on LIC809-C..

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette Romero	TELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023

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: TRANQUILITY VALLEY ASSISTED LIVING	FACILITY NUMBER: 331881166
	VISIT DATE: 08/28/2023

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Centrally Stored Medications: LPA observed a first aid kit with required components. Medications were secured in a kitchen cabinet. LPA reviewed physical medications for the residents along with the Medication Administration Record (MAR) used to log administration of residents' medication. LPA found that facility staff documented assistance with medications prior to dispensing medications. During review of the MAR for today's date (8/28/2023), the evening and bedtime columns were already initialed. Facility staff stated evening medications are given at 5:00 p.m. and bedtime medications are given at 8:00 p.m. Facility staff stated evening and bedtime medications had not been dispensed for 8/28/2023, and facility staff initialed the MAR in advance to avoid forgetting to do so later. Deficiency cited.

Bedrooms: Resident 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 grab bar in the shower. The hot water temperature measured at 116- and 118-degrees Fahrenheit. The facility has clean towels, blankets, and linen, available in different colors for the residents in care.

Laundry/Garage: LPA observed laundry room and garage to be clean. Washing machine and dryer are in good repair. Cleaning solutions and chemicals are secured in a locked cabinet in the laundry room. Emergency food supplies, water and incontinent supplies are stored in the garage.

Records: Staff present have a criminal record clearance on file but are not associated to the facility. Deficiency cited. The CPR/First Aid certification for Staff #1 and Staff #2 present expired on 9/4/2022. Deficiency cited.

Yard/Outside Area: A wood wall secured the entire backyard. All outdoor pathways were free of obstructions. No bodies of water were observed.

During today's visit, LPA observed three (3) deficiencies faulting the facility. An exit interview was conducted, and a copy of this report was reviewed and provided to Caregiver Camalig along with an LIC809-D, LIC412BG, and Appeals Rights.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette Romero	TELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/28/2023 02:30 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: TRANQUILITY VALLEY ASSISTED LIVING	FACILITY NUMBER: 331881166
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(c)(1)

87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. 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 due to LPA observing the CPR/First Aid for certification for Staff #1 and Staff #2 is expired, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/07/2023
	Plan of Correction
1 2 3 4	Licensee agreed to request Staff #1 and Staff #2 to renew their CPR/First Aid certification and provide proof of correction to CCLD by close of business on POC due date.

Type B

Section Cited

CCR

87465(a)(4)

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. 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 due to LPA finding that facility staff documented assistance with medication on MAR, prior to dispensing of medication, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/07/2023
	Plan of Correction
1 2 3 4	Licensee agreed to provide staff training regarding medication management, dispensing and documentation, and provide proof of practice to CCLD by close of business on 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: Janette Romero	TELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023

LIC809 (FAS) - (06/04)

Page: 4 of 4

Document Has Been Signed on 08/28/2023 02:30 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: TRANQUILITY VALLEY ASSISTED LIVING	FACILITY NUMBER: 331881166
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87355(e)(3)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or 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 by not associating Staff #1 and Staff #2 to the facility, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/07/2023
	Plan of Correction
1 2 3 4	Licensee agreed to request a transfer of a criminal record clearance and provide proof of correction to CCLD 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	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette Romero	TELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023

LIC809 (FAS) - (06/04)

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