331881285-5-1-2024-18-AS-JGEE-D4V2EY-20240501172044

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881285
Report Date: 05/01/2024
Date Signed: 05/01/2024 05:20:51 PM

Document Has Been Signed on 05/01/2024 05:20 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:	BETTY'S PLACE		FACILITY NUMBER:	331881285
ADMINISTRATOR:	BERG, MCCLAIN		FACILITY TYPE:	740
ADDRESS:	37182 SIERRA GROVE DRIVE		TELEPHONE:	(951) 316-1549
CITY:	MURIETA	STATE: CA	ZIP CODE:	92563
CAPACITY:	6	CENSUS: 6	DATE:	05/01/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:55 PM
MET WITH:	Andrew Hardin, Caregiver		TIME COMPLETED:	05:15 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	Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct a 1 year required visit. LPA was greeted and granted entry by Caregiver Andrew Hardin, the Administrator Ardie Crenshaw arrived shortly after. At the time of the visit there was (3) staff and (6) residents present. All staff were observed to have obtained criminal record clearance and were associated to the facility. LPA conducted a tour of the interior and exterior of the facility. LPA observed for the facility to be clean, clutter and odor free. The facility was observed to be at a comfortable temperature, the resident bedrooms, had the required furniture, bed, lighting, chest of drawers and chair. The smoke and carbon monoxide detectors are intertwined and were tested and observed to be operable. There is one (1) fire extinguisher hanging on the wall inside the kitchen. The water temperature was tested and was found to be within regulatory limits measuring between 115-120 degrees F. There are no pools or bodies of water observed on the premises, or no known guns or ammunition. The medications are stored in the garage in a locked medication cart and were observed to be inaccessible to residents in care. The medications were observed to be given as they were prescribed. The chemicals and sharp objects (knives) are stored in a locked closet in the hallway next to the laundry room. Records review: Resident files were reviewed and were found to have the required documentation such as medical assessments, appraisal and admissions agreements. 3 of 4 Staff files reviewed were observed to not have the required training such as valid Cardio Pulmonary Resuscitation (CPR). A deficiency will be issued. The facility food supply was observed to meet the requirements as there was a 2 day supply of perishable and a 7 day supply of nonperishable food items. LPA observed for there to be 3 cans of expired food and were discarded during the visit there no citation will be issued.

SUPERVISOR'S NAME: Tricia Danielson	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024

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 05/01/2024 05:20 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: BETTY'S PLACE	FACILITY NUMBER: 331881285
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 3 out of 3 times as S1 S2 and S4 did not posses vaild CPR certification, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/02/2024
	Plan of Correction
1 2 3 4	The licensee agrees to enroll and have staff complete CPR certification. POC is to be submitted 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: Tricia Danielson	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024

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: BETTY'S PLACE	FACILITY NUMBER: 331881285
	VISIT DATE: 05/01/2024

NARRATIVE

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The facility will submit the following to the regional office for follow up or filing by 5pm, Monday 5/6/24:

-LIC808-Mitigation Plan
-Addendum to plan of operation if the facility is going to use video surveillance, and an update copy of facility sketch indicating where the cameras are located in the facility
-Change of Administrator request
-A copy of liability insurance

Based on today's visit a citation will be issued in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8).

An exit interview was conducted and a copy of this report, 809D, appeal rights, and LIC9098 Proof of Corrections form was provided to Ardie Crenshaw.

SUPERVISOR'S NAME: Tricia Danielson	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024

LIC809 (FAS) - (06/04)

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