331881166-8-1-2024-18-AS-SMAZ-D7R25P-20240801170552

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881166
Report Date: 08/01/2024
Date Signed: 08/01/2024 05:06:04 PM

Document Has Been Signed on 08/01/2024 05:06 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:	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:	08/01/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:18 PM
MET WITH:	Nitin 'Nick' Vermani, Manager		TIME COMPLETED:	05:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA), Stephanie Martinez, conducted a required annual inspection at the facility. The LPA was allowed entrance into the facility and met with staff, Soledad Alcantara. The LPA later met with Nick Vermani, Manager, toward the end of the visit. He was notified of the purpose for the visit. The inspection included the following: Physical Plant: The facility consists of four (4) resident bedrooms, one (1) staff room, two (2) bathrooms, an open kitchen and dinning area, a living room area, a sitting/office space, a laundry room, a garage, and a patio and yard with sufficient seating and space for activities. There are no bodies of water located on the property. According to staff Soledad, no weapons are stored in the home. The facility is being maintained at a comfortable temperature. All outdoor and indoor passageways are kept free of obstruction and are free of debris and other trash. There are grab bars for each toilet, bathtub and shower used by residents. Resident showers have non-skid mats or strips present. The smoke and carbon monoxide device was tested by staff and found to be in operating condition. The home was clean and free of any odors. Food Service: There is a minimum of 2 days supply of perishable foods and 1 week's supply of non-perishable foods available. Sufficient dinning supplies were available for residents in care. A variety of food was available and stored in a safe and healthful manner. Record Review: All staff were observed to have appropriate fingerprint clearances. LPA did not observe any excluded individuals on the premises at time of visit. Staff responsible for direct care and supervision have current first aid and CPR training. Initial medication and Dementia Care training was observed to be complete. The facility was not operating beyond the conditions specified on the license. The facility currently has an approved Hospice Waiver for six (6) residents and there are currently no residents in care receiving hospice services. There is a disaster and mass casualty plan in place. Proof of emergency drills was

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie Martinez	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024

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: TRANQUILITY VALLEY ASSISTED LIVING	FACILITY NUMBER: 331881166
	VISIT DATE: 08/01/2024

NARRATIVE

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observed on file. Administrator, Teresa Fuentes, has an active administrator's certificate. During a review of records the LPA observed a Participant Care Plan to reveal Resident Two (R2) has a prohibited health condition. R2 is not receiving hospice services and no exception was submitted by the Licensee to retain R2. A citation will be issued.

Medication Review: The LPA inspected resident medications. Medications were observed to be appropriately labeled and inaccessible to unauthorized individuals.

An exit interview was conducted with Manager Vermani in which this report was reviewed and a copy was provided, along with the LIC 811, LIC 9098 and instructions on appeal rights.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie Martinez	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/01/2024 05:06 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: TRANQUILITY VALLEY ASSISTED LIVING	FACILITY NUMBER: 331881166
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87615(a)

Prohibited Health Conditions

(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: 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 in one out of one residents (R2) who has a prohibited health condition. R2 is not receiving hospice services and no exception was submitted by the Licensee to retain R2. This poses a potential health, safety and personal rights risk to persons in care.
	POC Due Date: 08/15/2024
	Plan of Correction
1 2 3 4	The manager reported an exception request will be submitted to the Department for the resident.

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: Stephanie Martinez	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024

LIC809 (FAS) - (06/04)

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