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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881166
Report Date: 11/22/2024
Date Signed: 11/22/2024 02:58:21 PM

Document Has Been Signed on 11/22/2024 02:58 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 LIVINGFACILITY NUMBER:
331881166
ADMINISTRATOR/
DIRECTOR:		FUENTES, TERESAFACILITY TYPE:
740
ADDRESS:26450 HELENE DRIVETELEPHONE:
(951) 807-3397
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY: 6CENSUS: 6DATE:
11/22/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:25 AM
MET WITH:Soledad Alcantara, StaffTIME VISIT/
INSPECTION COMPLETED:
03:10 PM
NARRATIVE
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Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the home to address violations observed. The LPA met with staff, Soledad Alcantara, and was allowed entry into the home. The LPA spoke with Administrator, Teresa Fuentes, over the phone and informed her of the purpose for the visit.

The LPA reviewed the file for Staff One (S1) and observed no date of employment, no signed statement regarding their criminal record history as required by Section 87355(d), and no documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e). The LPA reviewed the file for Staff Two (S2) and observed no date of employment, telephone number, educational background, past experience, no signed statement regarding their criminal record history as required by Section 87355(d), and no documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e). In addition, interviews revealed S1 is assisting Resident One (R1) with their finances, specifically holding onto their money. R1 was interviewed and reported S1 is holding onto $400 of their money. S1 was interviewed and reported they were holding onto $1,000 of R1's money. An additional staff interview revealed S1 and R1 have both reported S1 is in possession of R1's money. In addition, the LPA observed R1's wallet was being safeguarded in a locked drawer at the facility where only staff had access. A file review revealed through the Affidavit Regarding Client/Resident Cash Resources (LIC 400) that the facility was not to handle any cash resources for persons within the facility. R1's Admission Agreement was reviewed, and the report was found to indicate staff were not to handle cash resources for residents in care. When Administrator Fuentes was interviewed, she confirmed staff are not to be handling resident's cash resources. These violations pose a potential threat to the health, safety, and personal rights of the residents in care. Citations will be issued.

An exit interview was conducted with Administrator Fuentes over the phone and a copy was provided, along with the LIC 811 and instructions on appeal rights.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2024
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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Document Has Been Signed on 11/22/2024 02:58 PM - It Cannot Be Edited


Created By: Stephanie Martinez On 11/22/2024 at 09:33 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 11/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/06/2024
Section Cited
CCR
87412(a)

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Personnel Records: (a) The licensee shall ensure that personnel records are maintained on...each employee. Each personnel record shall contain the following...: This requirement was not met, as evidenced by: Based on record review, the licensee did not ensure personnel records contained required info.
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Administrator stated personnel records will be completed as required. She reported the staff records will be submitted to the Department as proof by the POC due date.
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Files for S1 and S2 contained no date of employment, no signed statement regarding their criminal record history, & no documentation of either a criminal record clearance or a criminal record exemption. File for S2 contained no, telephone #, educational background, or past experience.
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Type B
12/06/2024
Section Cited
CCR87208(a)

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Plan of Operation: (a) Each facility shall have and maintain a current, written definitive plan of operation...This requirement was not met, as evidenced by: Based on observation and interview, the licensee did not ensure the facility's plan of operation was maintained current. Interviews revealed S1
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Administrator stated S1 will be directed to return R1's funds and personal property. She reported S1 and S2 will be further educated on the facility's policies. Administrator reported proof of in-service training will be submitted to the Department by the POC date.
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is holding onto R1's money. LPA observed R1's wallet was being safeguarded in a locked drawer at the facility. An LIC 400 revealed that the facility was not to handle any cash resources for persons within the facility. R1's Admission Agreement revealed staff were not to handle cash resources for residents.
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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 Stamps
LICENSING EVALUATOR NAME:Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2024


LIC809 (FAS) - (06/04)
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