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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881331
Report Date: 05/22/2023
Date Signed: 05/22/2023 03:16:25 PM

Document Has Been Signed on 05/22/2023 03:16 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:ERICA B INDEPENDENT LIVING FACILITYFACILITY NUMBER:
331881331
ADMINISTRATOR:JOHNSON, LA SUNEAFACILITY TYPE:
735
ADDRESS:3656 GINGER STTELEPHONE:
(818) 818-1817
CITY:PERRISSTATE: CAZIP CODE:
92571
CAPACITY: 6CENSUS: 4DATE:
05/22/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Erica Graham Bullock, LicenseeTIME COMPLETED:
03:25 PM
NARRATIVE
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On 5/22/2023, Licensing Program Analyst (LPA) Chinwe Nwogene arrived unannounced to the facility to conduct a case management visit to check on the health, and safety of residents in care and to follow up on the SOC 341 received on 05/19/2023. LPA met with Licensee, Erica Graham Bullock and explained the purpose of the visit.

During the visit, LPA toured the inside and outside perimeter of the facility and observed no health and/or safety hazards. LPA interviewed staff, interviewed resident, reviewed resident file, and collected pertinent documents. During the interview LPA was informed resident #2 had refused to take medication for two #2 weeks leading up to the incident that happened on 5/17/2023. LPA asked Licensee, Erica if the resident refusal to take medication was reported to the department, Erica stated no. Also, during resident #2 file review, LPA observed the medication record was incomplete. There was no documentation of the time medication was given. Two citations will be issued.

There for based on the observation made during today’s visit, two #2 citations will be issued per Title 22, Division 6 of the California Code of Regulations. See LIC 809D. An exit interview was conducted, and this reported was provided along with appeal rights to Erica Graham Bullock.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE: DATE: 05/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2023
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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Document Has Been Signed on 05/22/2023 03:16 PM - It Cannot Be Edited


Created By: Chinwe Nwogene On 05/22/2023 at 02:04 PM
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: ERICA B INDEPENDENT LIVING FACILITY
FACILITY NUMBER: 331881331

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/01/2023
Section Cited
CCR
80061(a)

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Reporting Requirements;

(a) Each licensee or applicant shall furnish to the licensing agency reports as required by the Department, including, but not limited to, those specified in this section.
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Licensee stated moving forward incidents will be reported to the department accordingly and a written statement of understanding of the regulation cited will be provided to LPA by the POC due date 6/1/2023.
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This requirement is not met based as evidence by observation, interview, and record review. The licensee did not comply by not reporting resident #2's refusal to take medication to the department which poses a potential health, safety or personal rights risk to persons in care.
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Type B
06/01/2023
Section Cited
CCR80075(c)

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Health Related Services;

(C) A record of each dose is maintained in the client's record. The record shall include the date and time the medication was taken, the dosage taken, and the client's response.
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Licensee stated moving forward clients mediaction record will be updated and a written statement of understanding of the regulation cited will be provided to LPA by the POC due date 6/1/2023.
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This requirement is not met based as evidence by observation, interview, and record review. The licensee did not comply by not documenting the time the medication was taken which poses a potential health, safety or personal rights risk to persons in care.
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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 Esquivel
LICENSING EVALUATOR NAME:Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2023


LIC809 (FAS) - (06/04)
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