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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881255
Report Date: 12/27/2023
Date Signed: 12/27/2023 11:12:34 AM


Document Has Been Signed on 12/27/2023 11:12 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:CHERRY'S INFINITE CAREFACILITY NUMBER:
331881255
ADMINISTRATOR:VILLANUEVA, ROSARIOFACILITY TYPE:
740
ADDRESS:30720 AVENIDA DEL PADRETELEPHONE:
(347) 334-2979
CITY:CATHEDRAL CITYSTATE: CAZIP CODE:
92234
CAPACITY:6CENSUS: 6DATE:
12/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Administrator, Rosario "Cherry" VillanuevaTIME COMPLETED:
11:20 AM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola conducted a required annual visit. LPA was greeted and was granted entry and met with Administrator, Rosario "Cherry" Villanueva, who was informed of the purpose of the visit. At time of visit there were (6) residents and one (3) staff present.

The facility is a one story home with (6) bedrooms and (4) bathrooms with attached garage. The facility does not have a pool or fire arms. The facility is residential care facility for the elderly serving residents ages 60 and above. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following:

Infection Control: LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. The facility has a plan on how to mitigate infectious disease and train staff.

Physical Plant: Physical plant, floors, windows, and doors were observed to be clean and fixtures and furniture were present and in good repair. The facility's outdoor area was observed to be free of hazards. The sharp and dangerous objects were observed to be locked and inaccessible to clients. The smoke and carbon monoxide detectors were operational.

Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2023
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: CHERRY'S INFINITE CARE
FACILITY NUMBER: 331881255
VISIT DATE: 12/27/2023
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Record Review and Resident/Staff Files: LPA reviewed staff files and training that contained staff criminal clearance and updated training along with CPR/First Aid. Client files were reviewed and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: All client medication was locked in a kitchen cabinet LPA reviewed resident medications R1 and found medication (3) medications needed to be refilled. LPA also observed all medications for R1 were not initialed on MARS as given from 12/20/23 to 12/27/23. LPA also reviewed medication list from R1's physician's and found (2) medications that staff stated were discontinued but no physician's order to stop medications. Deficiency was documented and plan of correction was created with Licensee.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing last fire drill conducted May of 2023. Deficiency was cited and plan of correction was documented with Licensee. LPA observed all facility exits were clear from obstructions.

An exit interview was conducted where a copy of this report along with LIC809-D page, and appeal rights were provided to Administrator, Rosario "Cherry" Villanueva.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 12/27/2023 11:12 AM - 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: CHERRY'S INFINITE CARE
FACILITY NUMBER: 331881255

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above based on last drill that was conducted on May of 2023 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/03/2024
Plan of Correction
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The licensee stated they would conduct a drill by the POC date and send LPA documentation of the drill conducted.
Type B
Section Cited
CCR
87465(a)
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care...
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 with R1's medications which were not filled and medication list which did not reflect the accurate medication R1 is currently taking. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2024
Plan of Correction
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The administrator stated they would obtain an up to date medication list from R1's physican and maintined discontinuation orders for residents. Staff in service for medication documentation, and new procedure for Resident refill for R1. This is due to LPA 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: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2023
LIC809 (FAS) - (06/04)
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