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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881224
Report Date: 11/26/2024
Date Signed: 11/26/2024 11:57:21 AM

Document Has Been Signed on 11/26/2024 11:57 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:ARAGON MANORFACILITY NUMBER:
331881224
ADMINISTRATOR/
DIRECTOR:		ARAGON, MARIELAFACILITY TYPE:
740
ADDRESS:33785 TAMERRON WAYTELEPHONE:
(951) 245-4244
CITY:WILDOMARSTATE: CAZIP CODE:
92595
CAPACITY: 4CENSUS: 4DATE:
11/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Licensee/Administrator Mariela AragonTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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On 11/26/2024 at 08:50 AM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Brown met with Licensee/Administrator Mariela Aragon and was granted entry to the facility. At the time of the visit there were two (2) staff present, and four (4) residents present. LPA Brown explained the purpose of the visit to Licensee/Administrator Aragon.

The facility has six (6) bedrooms, in which three (3) bedrooms are designated for residents, and three (3) bedrooms are designated for staff/family, three (3) bathrooms, living room, kitchen, dining area, backyard, and attached garage. The facility is a Residential Care Facility for the Elderly (RCFE) licensed for a capacity of four (4) non-ambulatory residents and of which two (2) residents may be bedridden. The current census is four (4) residents. The facility has approved hospice waiver for three (3) residents. LPA Brown was accompanied by Licensee/Administrator Aragon to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). The buildings and grounds were free from hazards. Outdoor and indoor passageways were kept free of obstruction. LPA observed an in-ground pool in the backyard, the perimeter of pool is gated and locked. The facility is maintained at a comfortable temperature of 72 degrees Fahrenheit. LPA Brown inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA Brown observed sufficient furniture and lighting throughout the facility. LPA Brown measured and observed the water temperature in the residents shared bathroom to be at 128.1 degrees Fahrenheit. Deficiency will be issued. Also, LPA Brown noted no night lights maintained in hallways and passages to non private bathrooms. Deficiency will be issued. Moreover, LPA Brown observed one (1) window screen in disrepair. Technical Violation will be issued. ***Continuation in LIC809C***

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: ARAGON MANOR
FACILITY NUMBER: 331881224
VISIT DATE: 11/26/2024
NARRATIVE
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 The facility is equipped with operating smoke detectors and carbon monoxide alarms. In addition, LPA Brown observed auditory signal that's loud enough to summon staff at the facility. Postings such as the facility license, personal rights, the CCLD complaint poster, ombudsman poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. Medications are kept inside the medication cabinet in the kitchen inaccessible to residents.

Food Service: Seven (7) days non-perishable and two (2) days perishable food supply observed at the facility.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. LPA Brown observed that there's a staff scheduled to work the night shift as required for facility with dementia residents.

Record Review: LPA Brown observed the facility's Infection Control Plan and updated Liability Insurance maintained at the facility. Emergency supplies, food, water were observed at the facility. However, LPA Brown noted that the facility's Emergency Plan (LIC610E) was not reviewed annually, without Licensee's signature and date as evidenced of last signature date observed on form LIC610E was 07/05/2019. Deficiency will be issued. Furthermore, LPA Brown reviewed two (2) resident files for admission agreements, updated physician reports, pre-placement appraisals, Centrally Stored Medication List and Needs and services plans. The files reviewed were complete. LPA reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test results and LPA Brown observed that files reviewed were complete.

LPA Brown audited two (2) residents medications and LPA Brown observed that staffs at the facility are not assisting Resident #1 (R1) with one (1) medication and Resident #2 (R2) with one (1) medication per their physician's order as evidenced of discrepancies noted in actual quantity of the medications per their centrally stored medication list. Deficiency will be issued.

Based on the observations made during today’s visit, deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809) was discussed and provided to Licensee/Administrator Mariela Aragon.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 11/26/2024 11:57 AM - It Cannot Be Edited


Created By: Melody Brown On 11/26/2024 at 11:04 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
, CA 92507

FACILITY NAME: ARAGON MANOR
FACILITY NUMBER: 331881224

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that the haot water in resident shared bathroom's maintained to not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2024
Plan of Correction
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Licensee stated to regulate the hot water is residents shared bathroom to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C) and submit proof to LPA Brown on Plan of Correction (POC) due date.
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that staffs at the facility are assisting Resident #1 (R1) with one (1) medication and Resident #2 (R2) with one (1) medication per their physician's order as evidenced of discrepancies in actual quantity of the medications per their centrally stored medication list observed during medication audit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2024
Plan of Correction
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Licensee stated to utilize medication record/Medication Administration Record (MAR) for all residents and submit proof to LPA Brown on Plan of Correction (POC) due date. Also, Licensee stated to train all staff on CCR 87465(a)(4) and submit proof of all staff training log to LPA Brown 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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 11/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/26/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 11/26/2024 11:57 AM - It Cannot Be Edited


Created By: Melody Brown On 11/26/2024 at 11:04 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
, CA 92507

FACILITY NAME: ARAGON MANOR
FACILITY NUMBER: 331881224

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(5)
Personal Accommodations and Services
(5) Night lights shall be maintained in hallways and passages to nonprivate bathrooms.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that night lights were maintained in hallways and passages to nonprivate bathrooms which posesa potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2024
Plan of Correction
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Licensee stated to obtain/purchase night lights and install on hallways and passages to nonprivate bathrooms and submit proof to LPA Brown on Plan of Correction (POC) due date.
Type B
Section Cited
HSC
1569.695(d)
Other Provisions
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that the facility's Emergency Plan (LIC610E) was reviewed annually, signed with date sign and date as evidenced of last signature date observed 07/05/2019 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2024
Plan of Correction
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Licensee reviewed, signed with date sign the the facility's Emergency Plan (LIC610E) during the visit. POC cleared.
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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 11/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/26/2024


LIC809 (FAS) - (06/04)
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