331881237-4-26-2024-18-AS-JARA-D4PU9N-20240426152326

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881237
Report Date: 04/26/2024
Date Signed: 04/26/2024 03:23:33 PM

Document Has Been Signed on 04/26/2024 03:23 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:	OUR LEGACY LLC		FACILITY NUMBER:	331881237
ADMINISTRATOR:	RODRIGUEZ, JEANNETTE		FACILITY TYPE:	740
ADDRESS:	13000 WILD SAGE LN		TELEPHONE:	(951) 575-7775
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92555
CAPACITY:	6	CENSUS: 5	DATE:	04/26/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:50 PM
MET WITH:	Administrator, Jeannette Rodriguez		TIME COMPLETED:	03:45 PM

NARRATIVE

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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit. LPA was granted entry and met with Administrator, Jeannette Rodriguez who was informed of the purpose of the visit. At the time of the visit there was (1) staff and (5) residents present.

The facility is a one story home with (5) bedrooms and (3) bathrooms for clients. No pool or firearms are present at the facility. The facility is a residential care home for the elderly approved for (6) non-ambulatory. LPA found through records review and interview that (1) resident was confirmed to be bedridden. The facility was cited for not having the appropriate fire clearance, Plan of correction was created.

Infection Control: The LPA observed the hand hygiene supplies, PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan.

Physical Plant: Physical plant was observed to be clean and fixtures and furniture were in good repair. LPA observed client bedrooms and bathrooms, kitchen, living areas, and out door area. No health and safety issues were observed. The carbon monoxide detector was functional and hot water temperature was 120F.

Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. Perishable and non-perishable items were observed to be in required amounts.

Record Review and Resident/Staff Files: LPA reviewed staff files and training, and resident files. LPA reviewed (5) resident files, (3) did not have a written care plan. The facility was cited and a plan of correction was created. LPA review the staff training, all staff have completed required training corroborated through interview. The documentation for the training will be sent to the LPA by Monday 4/29/2024.

SUPERVISOR'S NAME: Tricia Danielson	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-233-6759
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2024

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: OUR LEGACY LLC	FACILITY NUMBER: 331881237
	VISIT DATE: 04/26/2024

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Health Related Services/ Incidental Medical Services: All resident medication was locked in a hallway closet. Medication was accounted for on the MARS list.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. The facility has not conducted a fire drill since being licensed. Technical note was documented for staff to conduct drill and send to LPA by 4/29/2024.

An exit interview was conducted where a copy of this report was reviewed and provided to Administrator, Jeannette Rodriguez.

SUPERVISOR'S NAME: Tricia Danielson	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-233-6759
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/26/2024 03:23 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: OUR LEGACY LLC	FACILITY NUMBER: 331881237
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87202(a)

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above with (1) resident that was found to be bedridden. The facility does not have a fire clearance for this resident which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/03/2024
	Plan of Correction
1 2 3 4	The licensee agreed to submit request for bedridden clearance to the LPA by the POC due date.

Type B

Section Cited

CCR

87467(a)

(a) Prior to, or within two weeks of the resident’s admission, the licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident’s preferences regarding the services provided at the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above with (3) resident that did not have a record of care which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/03/2024
	Plan of Correction
1 2 3 4	The licensee agreed to have a written care plan for all residents and send proof of (3) resident care plans by 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: Tricia Danielson	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-233-6759
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2024

LIC809 (FAS) - (06/04)

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