331881332-8-28-2023-18-AS-JROO-CV5PZV-20230828114611

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881332
Report Date: 08/28/2023
Date Signed: 08/28/2023 11:46:16 AM

Document Has Been Signed on 08/28/2023 11:46 AM - 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:	SPENCER'S 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:	08/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Caregiver Marites Barcello		TIME COMPLETED:	12:00 PM

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On 8/28/2023, Licensing Program Analyst (LPA) Janette Romero arrived unannounced at the facility to conduct an annual required visit. LPA was greeted and granted entry by Caregiver Marites Barcelo who was informed of the purpose of visit. During the visit, four (4) residents and two (2) staff present.

The facility is approved to care for six (6) non-ambulatory residents and has a hospice waiver for three (3). The facility is made up of four (4) resident bedrooms, two (2) resident bathrooms, a kitchen, dining room, living/family area, laundry room and garage.

During the visit, LPA observed the following:

Kitchen: LPA observed kitchen to be clean. Food is stored in a safe and healthful manner. Sharps are secured in a locked kitchen drawer. The facility has a 7-day supply of non-perishable food items, but did not have a 2-day supply of perishable food items. Deficiency cited.

Dining and Living room: LPA toured the dining and living/family room area. LPA observed areas to be clean and furniture in good condition. LPA observed residents watching television in the living room and sleeping in their rooms. Fire extinguisher is charged and mounted in the dining room.

Hallway: LPA observed hallway to be clean with no pathway obstruction. Carbon monoxide and smoke detector were tested and functioning properly.

Continued on LIC809-C..

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette Romero	TELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023

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: SPENCER'S CROSSING SENIOR ASSISTED LIVING LLC	FACILITY NUMBER: 331881332
	VISIT DATE: 08/28/2023

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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 two residents along with the digital Medication Administration Record (MAR) and did not observe any discrepancies.

Hallway: LPA observed hallway to be clean with no pathway obstruction. Carbon monoxide and smoke detector were tested and functioning properly.

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

Bathrooms: Bathrooms have a working toilet, wash basin, and were equipped with a grab bar in the shower. The hot water temperature measured at 108-degrees Fahrenheit. The facility has clean towels, blankets, and linen, available in different colors for the residents in care.

Laundry/Garage: LPA observed laundry room and garage to be clean. Washing machine and dryer are in good repair. Cleaning solutions and chemicals are secured in a locked cabinet in the laundry room. Emergency food supplies, water and incontinent supplies are stored in the garage.

Records: Staff present have a criminal record clearance on file and are associated to the facility. Staff present have a current CPR/First Aid certificate.

Yard/Outside Area: Covered patio seating is available for residents. A brick wall secured the entire backyard. 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 Caregiver Barcelo along with an LIC809-D and Appeals Rights.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette Romero	TELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/28/2023 11:46 AM - 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: SPENCER'S CROSSING SENIOR ASSISTED LIVING LLC	FACILITY NUMBER: 331881332
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(26)

87555 General Food Service Requirements (b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. 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 the facility did not have a 2-day supply of perishable food items on the premises, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/07/2023
	Plan of Correction
1 2 3 4	Licensee agreed to purchase perishable food items and submit proof of correction and 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	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette Romero	TELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023

LIC809 (FAS) - (06/04)

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