331881311-8-22-2023-18-AS-JROO-CUXQLB-20230822121536

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881311
Report Date: 08/22/2023
Date Signed: 08/22/2023 12:15:42 PM

Document Has Been Signed on 08/22/2023 12:15 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:	CENTINELLA ADULT RESIDENTIAL CARE HOME		FACILITY NUMBER:	331881311
ADMINISTRATOR:	BOYER, MARITES		FACILITY TYPE:	735
ADDRESS:	820 CENTINELLA COURT		TELEPHONE:	(951) 658-2350
CITY:	HEMET	STATE: CA	ZIP CODE:	92544
CAPACITY: 6		CENSUS: 5	DATE:	08/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:55 AM
MET WITH:	Administrator Marites Medina		TIME COMPLETED:	12:30 PM

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On 8/22/2023, Licensing Program Analyst (LPA) Janette Romero arrived unannounced at the facility to conduct a required annual inspection. LPA was greeted and granted entry by Caregive Nilo Medina who was informed of the purpose of the visit. Acting Administrator Marites Medina arrived during the visit.

During the visit, there was three (3) staff and one (1) client present, and LPA was informed that four (4) clients were at day program. The facility is approved to care for six (6) clients and serves adults ages 18 through 59. LPA toured the facility's interior and exterior and observed the following:

Kitchen: LPA observed kitchen area to be clean. Food is stored in a safe and healthful manner. LPA observed the facility had a 2-day supply of perishable foods and 7-day of non-perishable food items. Knives/sharp instruments are secured in a locked kitchen drawer.

Dining and Living room: LPA toured the dining and living/family room area. LPA observed an open area in the living room ceiling measuring approximately 4 feet by 2 feet. LPA was informed the ceiling area has been open for approximately one (1) month and water leaks through the ceiling when it rains. Deficiency cited.

Hallway: LPA toured the hallway and observed hallway to be clean with no pathway obstruction. Facility has a fire alarm system. Carbon monoxide and smoke detector were tested and functioning properly.

Continued on LIC809-C..

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CENTINELLA ADULT RESIDENTIAL CARE HOME	FACILITY NUMBER: 331881311
	VISIT DATE: 08/22/2023

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Centrally Stored Medications: LPA observed a first aid kit with required components. Medications were secured in a kitchen cabinet. LPA reviewed physical medications for Client #1 as well as Medication Administration Record, no discrepancies discovered.

Bedrooms: Client bedrooms were clean and each furnished with a bed, chair, closet, clothing storage and lighting.

Bathrooms: Bathroom has a working toilet, wash basin, and were equipped with a grab bar in the shower. The hot water temperature measured at 105-degrees Fahrenheit. The facility has clean towels, blankets, and linen, available in different colors for the clients in care.

Laundry/Garage: LPA toured the laundry room garage. Washing machine and dryer are in good repair. Cleaning solutions and chemicals are secured in locked laundry room. Emergency food supplies, water, additional hygiene supplies, linen and towels are stored in the garage.

Records: Staff present have a criminal record clearance on file and are associated to the facility. Staff training is up to date.

Yard/Outside Area: Shaded outside seating area is available for the clients to sit and relax. All outdoor pathways were free of obstructions. No bodies of water were observed. There were no firearms or ammunition observed at the facility, and LPA was informed the facility will not store firearms or ammunition on the premises.

During today’s visit, LPA observed one deficiency faulting the facility. An exit interview was conducted, and a copy of this report was reviewed and provided to Acting Administrator Medina along with an LIC809-D and Appeals Rights.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/22/2023 12:15 PM - It Cannot Be Edited

Created By: Janette Romero On 08/22/2023 at 11:56 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
RIVERSIDE, CA 92507

FACILITY NAME: CENTINELLA ADULT RESIDENTIAL CARE HOME	FACILITY NUMBER: 331881311
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above due to LPA observing a large open area in the living room ceiling, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/05/2023
	Plan of Correction
1 2 3 4	Licensee agreed to repair the ceiling and provide proof of correction to CCLD by close of business on POC due date.

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:

Joel Esquivel

LICENSING EVALUATOR NAME:

Janette Romero

LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

LIC809 (FAS) - (06/04)

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