331881357-8-1-2023-18-AS-SMAZ-CUB2CX-20230801171727

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881357
Report Date: 08/01/2023
Date Signed: 08/01/2023 05:17:34 PM

Document Has Been Signed on 08/01/2023 05:17 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:	ST. JEANNE CARE HOME LLC		FACILITY NUMBER:	331881357
ADMINISTRATOR:	DERAMAS, MIRAFE		FACILITY TYPE:	740
ADDRESS:	10225 BONITA AVE		TELEPHONE:	(707) 704-4400
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92503
CAPACITY:	6	CENSUS: 5	DATE:	08/01/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Mirafe Deramas - Administrator		TIME COMPLETED:	05:30 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, Mirafe Deramas, who was informed of the purpose of the visit. At the time of the visit there was three (3) staff and four (4) residents present.

The facility is a one-story with four (4) bedrooms, two (2) bathrooms, two sitting areas, and a backyard. The clients served are elderly adults 65 years old. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted a staff and resident 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 resident bedrooms and staff office. Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. 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 117F.

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 Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Sara Martinez	TELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023

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: ST. JEANNE CARE HOME LLC	FACILITY NUMBER: 331881357
	VISIT DATE: 08/01/2023

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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) resident files were reviewed, and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: All resident medication was locked in a cabinet located in the kitchen. LPA reviewed medications for (3) residents and found all medication listed on MARS and all required labeling was found to be in place. LPA observed MARS for three out of five residents that did not have signatures from staff indicating medication had been dispensed to the residents since 07/30/2023. A deficiency will be issued along with a plan of correction.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing the facility's last fire and earthquake drills, which met the department requirements. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies in the storage and first aid kit with all required items.

An exit interview was conducted where a copy of this report along, LIC809D, and appeal rights were reviewed and provided to the Administrator, Mirafe Deramas.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Sara Martinez	TELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/01/2023 05:17 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: ST. JEANNE CARE HOME LLC	FACILITY NUMBER: 331881357
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(a)(4)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by the discrepancies discovered by LPA on three out of five Medication Administration Record (MAR), which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/08/2023
	Plan of Correction
1 2 3 4	Facility agreed to provide staff training regarding dispensing medication and proper documentation for resident's MARs. Proof of correction to be submitted 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: Sara Martinez	TELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023

LIC809 (FAS) - (06/04)

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