331881212-12-4-2023-18-AS-JGEE-CY7SBT-20231204124427

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881212
Report Date: 12/04/2023
Date Signed: 12/04/2023 12:44:35 PM

Document Has Been Signed on 12/04/2023 12:44 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:	DELICARE HEALTH SERVICES		FACILITY NUMBER:	331881212
ADMINISTRATOR:	AWAD, SAMEH		FACILITY TYPE:	740
ADDRESS:	31416 CHEMIN CHEVALIER		TELEPHONE:	(909) 559-7200
CITY:	TEMECULA	STATE: CA	ZIP CODE:	92591
CAPACITY:	6	CENSUS: 6	DATE:	12/04/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Sameh Awad, Administrator		TIME COMPLETED:	01:00 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	On 12/04/23 Licensing Program Analyst (LPA) Javina George arrived unannounced to the facility noted above to conduct an annual inspection. LPA was greeted and granted entry by Caregiver Leonora Martinez. LPA met with the Administrator Sameh Awad who arrived after LPAs arrival. Below is an account of LPAs observations of the conducted inspection: Physical plant: The facility was observed to be within the licensed capacity (6). The facility is a single story home with (5) resident bedrooms, (1) staff bedroom, (2.5) bathrooms, garage, living room, and backyard. The exterior was observed to be clutter free and well manicured. The video utilizes video surveillance, as cameras in all the common areas. The facility completed an addendum and obtained all required from the residents and their responsible parties. Interior: the resident bedrooms were observed to have clean mattresses, night stands, storage space, and sufficient lighting. Room temperatures were comfortable for residents in care. The bathroom appliances were operating in safe and sanitary conditions. LPA measured the hot water temperature in two (2) resident bathrooms, initially the water temperature was too hot, the water heater was adjusted and the water temperature ranges were retested and observed to be within regulatory limits of 108-114 degrees Fahrenheit. The carbon monoxide and smoke detectors l were observed to be operable. The facility was stocked with a 2-day supply of perishable and 7-day supply of non-perishable food items that were labeled appropriately. Dishes, glasses, and utensils were in good condition and stored in a healthful manner.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023

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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: DELICARE HEALTH SERVICES	FACILITY NUMBER: 331881212
	VISIT DATE: 12/04/2023

NARRATIVE

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There is a locked and centralized storage area for medications, which is located in the kitchen next to the refrigerator. The facility had a designated area for resident files and staff files. All staff present have a criminal record clearance on file and are associated to the facility. The facility was observed to have all the required postings such as Ombudsman poster, PUB475, LIC610E, and current administrator's certificate.

The facility was also equipped with a complete first aid kit as well as the first aid manual. LPA inspected the outdoor area of the facility. There was shaded area with seating. The facility is in compliance as the business' governing body is active and functioning. Overall, the facility was clean odor free and in good repair.

The following citations are being issued as the facility has not been conducting emergency disaster drills on a quarterly basis nor documenting the conducted drills. The citation can be found on the attached 809D.

An exit interview was conducted and a copy of the report, 809D, and appeal rights were reviewed and provided to Sameh Awad, administrator.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/04/2023 12:44 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: DELICARE HEALTH SERVICES	FACILITY NUMBER: 331881212
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.695(C)

This requirement is not met as evidenced by: The licensee did not ensure that the facility conducted a emergency disaster drill on a quarterly basis and document it.
	Deficient Practice Statement
1 2 3 4	Based on interviews and record review, the licensee did not comply with the section cited above in 1 out of 1 times which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/05/2023
	Plan of Correction
1 2 3 4	The Licensee agrees to conduct an emergency disater drill and document it, and as required therafter on a quarterly basis. Proof of POC correction is due to the department by 5pm on the due date indicated.

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: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023

LIC809 (FAS) - (06/04)

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