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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881301
Report Date: 07/13/2023
Date Signed: 07/13/2023 04:01:14 PM


Document Has Been Signed on 07/13/2023 04:01 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:A DRESSAGE HOME CAREFACILITY NUMBER:
331881301
ADMINISTRATOR:LABASTIDA, ROMEO G.FACILITY TYPE:
740
ADDRESS:12029 DRESSAGE LANETELEPHONE:
(714) 206-1964
CITY:RIVERSIDESTATE: CAZIP CODE:
92503
CAPACITY:6CENSUS: 6DATE:
07/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Romeo Labastida - AdministratorTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit. LPA was granted entry and met with Administrator, Romeo Labastida, who was informed of the purpose of the visit. At the time of the visit there was two (2) staff and six (6) residents present.

The facility is a one-story home with (6) bedrooms and (2) bathrooms with attached garage. The residents served are elderly adults 65 years of age and older. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted a staff and client interviews. LPA observed the following:

Infection Control: The LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements. LPA reviewed staff records and found that all staff had infection control training.



Physical Plant: LPA observed the client bedrooms and staff office. Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were present and in good repair. The outdoor area was observed to be free of hazards. LPA observed outdoor furniture and shaded area for residents. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to clients. The smoke detector and carbon monoxide was operational, and the hot water temperature 113.6 F.

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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:
DATE: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2023
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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: A DRESSAGE HOME CARE
FACILITY NUMBER: 331881301
VISIT DATE: 07/13/2023
NARRATIVE
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Care & Supervision/Administration: Adequate staff are present for the supervision of residents during the visit. LPA also reviewed the staff scheduled showing adequate staff coverage. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The listed administrator, possesses a current administrator's certificate.

Record Review and Resident/Staff Files: LPA reviewed two (2) staff files and training. All staff have criminal clearance and updated training along with CPR/First Aid Certification. Three (3) client files were reviewed and possessed all required paperwork.



Health Related Services/ Incidental Medical Services: All resident medication was locked in a closet. LPA reviewed medications for three (3) residents. Resident # 1 (R1) MARS was observed to not have had administration date signature for the morning medication taken on 07/13//2023. A deficiency will be issued as well as a plan of correction. Medication listed on MARS had all required labeling and was found to be accurate and in place.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. Administrator could not provide documentation showing the facility's last fire and earthquake drills and stated the last time they conducted a fire drill was approximately a year ago, which does not meet the Department minimum requirements. A deficiency will be issued as well as a plan of correction. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies in the garage and first aid kit with all required items.

An exit interview was conducted where a copy of this report, LIC809D, and appeal rights was provided to Administrator, Romeo Labastida.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 07/13/2023 04:01 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: A DRESSAGE HOME CARE

FACILITY NUMBER: 331881301

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 07/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(5)


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 based on having one out of six residents not having their MARs log signed for the morning medication administration for Resident # 1 (R1) for 07/13/2023 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/20/2023
Plan of Correction
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The Licensee shall ensure medication will be logged daily by the administer and will provide a statement as proof of staff training on Title 22 regulations on proper medication procedures. Proof will be submitted by the Department by the agreed POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:
DATE: 07/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 07/13/2023 04:01 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: A DRESSAGE HOME CARE

FACILITY NUMBER: 331881301

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 07/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(l)(8)


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 in conducting a fire/earthquake drill based off the deparment's requirments when caring for residents with dementia. The last time a fire/earthquake drill was conducted was last year which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/20/2023
Plan of Correction
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The Licensee shall ensure fire and earthquake drills will be conducted and logged quartely every year by the administer and will provide a statement as proof of staff training on Title 22 regulations on proper fire and earthquake drills. Proof will be submitted by the Department by the agreed POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:
DATE: 07/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5