331881332-8-10-2022-18-AS-YDEO-CH6UYX-20220810160019

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881332
Report Date: 07/14/2022
Date Signed: 08/10/2022 04:00:59 PM

Document Has Been Signed on 08/10/2022 04:00 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	SPENCERS CROSSING SENIOR ASSISTED LIVING LLC		FACILITY NUMBER:	331881332
ADMINISTRATOR:	BARROSO, MARIBEL		FACILITY TYPE:	740
ADDRESS:	35681 SILVERWEED RD		TELEPHONE:	(951) 719-0270
CITY:	MURRIETA	STATE: CA	ZIP CODE:	92563
CAPACITY:	6	CENSUS: 4	DATE:	07/14/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	10:05 AM
MET WITH:	Maribel Barroso, Licensee/Administrator		TIME COMPLETED:	01:15 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) Yolanda Delgado conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. At approximately 10:05 AM, LPA met with Licensee/Administrator Maribel Barroso. An initial application for Change of Ownership to operate a Residential Care for the Elderly facility (RCFE) was submitted to the Central Applications Bureau (CAB) on 3/10/2022 for a total capacity of six (6) non-ambulatory residents and zero (0) bedridden. Fire clearance was granted on 4/15/2022. LPA Delgado observed the following: Structure: Facility was a one-story house with four (4) resident bedrooms, two and half (2.5) resident bathrooms, living room, dining area and kitchen. There was an attached two car garage in the front of the house. Heating/Cooling System: Central heating and air conditioning system installed with a central panel located in the hallway to control entire house. Bedrooms: Each resident bedroom #1 (shared), #2, #3 and #4 will accommodate any non-ambulatory residents. 4 resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and an operable smoke alarm. Bathrooms: The (2.5) resident bathrooms has a working toilet, wash basin, and shower with an adequate supply of paper towels, toilet paper, and soap. At 11:11 AM, LPA tested the water temperatures in the resident bathrooms. LPA verified water temperature was measured at 97.1 degrees Fahrenheit. Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots and pans were observed. Knives/sharp instruments were secured in a locked closet located in the kitchen. There was adequate room for food storage. LPA observed the stove to be operational except for center burner. Refrigerator/freezer were in working condition. (CONTINUED ON LIC 809C)

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda Delgado	TELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022

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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SPENCERS CROSSING SENIOR ASSISTED LIVING LLC	FACILITY NUMBER: 331881332
	VISIT DATE: 07/14/2022

NARRATIVE

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CONTINUED FROM LIC 809)
and had sufficient storage for perishable food. There was adequate seating for meals for all clients. Laundry room with washer and dryer was located inside house. Laundry detergents and cleaning supplies were observed in house away from residents.
Living/Family room:
There was a living/family room with for all clients and TV.
Linens and Hygiene Supplies:
An adequate supply of linens was stored in a cabinet in the main hallway of the residence.
Yards/Outside:
Patio table and four chairs were observed in the backyard; more chairs are needed. There was a gate on the North side of the property with a self-latching hook. All outdoor pathways were free of obstructions. The patio screen door that leads from Bedroom #1 is tattered and ripped. Garage has previous owner's supplies and current resident's personal items stored.
Emergency Phone Numbers, and Exit Plan:
Facility sketch were observed posted at all the exits and each bedroom. Obudsman poster and Let-Us-No poster observed.
General items:
One (1) fire extinguishers were charged and located in the hallway by the kitchen. Seven (7) smoke alarms and eight (8) carbon monoxide detectors were tested and were observed to be in working order. Client records will be stored in a cabinet in the Kitchen. First Aid kit with required components are stored in a cabinet in the small hallway near the 1/2 bathroom, The medications are stored in a locked closet in the kitchen was observed. LPA observed a facility phone and it was verified to be operational as evidenced by LPA dialing the number to trigger a ring. Emergency water supply was not observed and the required 72-hour emergency food supply was not sufficient. Component III was completed on this day as well.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda Delgado	TELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022

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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SPENCERS CROSSING SENIOR ASSISTED LIVING LLC	FACILITY NUMBER: 331881332
	VISIT DATE: 07/14/2022

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Pre-Licensing is incomplete and the following corrections to be resolved by 7/28/2022:

obtain a separate 72-hour emergency food supply
obtain separate emergency water
obtain and post visiting policy
obtain 30-Days of PPE supplies
obtain additional seating for outdoor patio
obtain a stand in 1/2 bathroom for paper towel holder
obtain Infection Control screening protocols for Staff, Residents and Visitors
post additional Infection Control signage in common areas
maintain facility phone is plugged in and operational 24/7
remove extra furnishings from garage
remove non-operational interior door alarms
repair center burner on stove
repair patio door screen in Bedroom #1
replace all trash cans in bathrooms with lids
replace cabinets with locks for files and first aide kits
adjust water temperature to 106 degrees Fahrenheit for all sinks and showers by licensed Plumber

An exit interview was conducted, and a copy of this report was given.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda Delgado	TELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022

LIC809 (FAS) - (06/04)

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