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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881421
Report Date: 07/31/2024
Date Signed: 07/31/2024 05:58:56 PM

Document Has Been Signed on 07/31/2024 05:58 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:SMITH ROAD ASSISTED LIVINGFACILITY NUMBER:
331881421
ADMINISTRATOR/
DIRECTOR:		LECITA, MA SATCHELFACILITY TYPE:
740
ADDRESS:753 SMITH ROADTELEPHONE:
(951) 927-8178
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY: 12CENSUS: 10DATE:
07/31/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Ma Satchel Lecita, AdministratorTIME VISIT/
INSPECTION COMPLETED:
06:10 PM
NARRATIVE
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Licensing Program Analyst (LPA), Stephanie Martinez, continued a required annual inspection at the facility that was started on 06/18/2024. The LPA was allowed entrance into the facility and met with Administrator, Ma Satchel Lecita. The LPA informed the Administrator of the purpose for the visit. The inspection included the following:

Physical Plant: The facility consists of eight (8) resident bedrooms, three (3) bathrooms, a garage, an open kitchen and dinning areas, a living room area, an office area, a laundry room, and a patio and yard with sufficient seating and space for activities. There are no bodies of water located on the property. According to Administrator Lecita, no weapons are stored in the home. The facility is being maintained at a comfortable temperature. All outdoor and indoor passageways are kept free of obstruction and are free of debris and other trash. There are grab bars for each toilet, bathtub and shower used by residents. Resident showers have non-skid mats or strips present. The smoke and carbon monoxide devices were tested by the Administrator and was observed to be in operating condition. The home was kept clean, organized and free of any odors.

Record Review: All staff were observed to have appropriate fingerprint clearances. LPA did not observe any excluded individuals on the premises at time of visit. The facility was not operating beyond the conditions specified on the license. The facility currently has an approved Hospice Waiver for five (5) residents and there is currently one (1) residents in care receiving hospice services. There is a disaster and mass casualty plan in place. Three out of three staff members (S1 - S3) do not have current First Aid training on file. A citation will be issued. Two out of two staff members (S2 and S4) did not have the 20 hours of required annual training (Dementia, Postural Supports, Restricted Health Conditions or Hospice). A citation will be issued. One out of one staff members (S2) does not have the complete 10 hours of initial medication training. S2 only has 2 hours of medication training from 05/30/2023. According to Administrator, S2 started
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 07/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/31/2024
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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SMITH ROAD ASSISTED LIVING
FACILITY NUMBER: 331881421
VISIT DATE: 07/31/2024
NARRATIVE
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employment on 05/30/2023. A citation will be issued. Five out of five residents (R1 - R5) did not have a written record of care on file. A citation will be issued. Two out of two residents (R1 and R5) have a restricted health condition. According to staff the residents can manage their own treatment/care; however, neither had documentation on file indicating the residents can manage their own health conditions. A citation will be issued. One out of one residents (R6) did not have a hospice care plan on file. A citation will be issued.

Medication Review: The LPA inspected resident medications. Medications were observed to be well organized, appropriately labeled and inaccessible to unauthorized individuals. Two out of two residents (R1 and R7) medications were being stored in weekly medication containers. A citation will be issued.

An exit interview was conducted with Administrator Lecita in which this report was reviewed and a copy was provided, along with the LIC 811s, LIC 9098, and instructions on appeal rights.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 07/31/2024 05:58 PM - It Cannot Be Edited


Created By: Stephanie Martinez On 07/31/2024 at 05:03 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: SMITH ROAD ASSISTED LIVING
FACILITY NUMBER: 331881421

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on record review, the licensee did not comply with the section cited above in three out of three staff members (S1 - S3) who did not have current First Aid training on file. This poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 08/07/2024
Plan of Correction
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Administrator stated first aid training will be completed and proof of training will be submitted to the Department.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in two out of two staff members (S2 and S4) who did not have the 20 hours of annual training This poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 08/31/2024
Plan of Correction
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Administrator stated the required training will be completed and proof submitted to the Department.
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:Rikesha Stamps
LICENSING EVALUATOR NAME:Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 07/31/2024 05:58 PM - It Cannot Be Edited


Created By: Stephanie Martinez On 07/31/2024 at 05:03 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: SMITH ROAD ASSISTED LIVING
FACILITY NUMBER: 331881421

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.69(a)(2)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one out of one staff members (S2) who does not have the complete initial hours of training. S2 only has 2 hours of medication training from 05/30/2023. According to Administrator, S2 started employment on 05/30/2023. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/14/2024
Plan of Correction
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Administrator stated training will be completed and proof of training will be submitted to the Department.
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in two out of two residents (R1 and R7) whose medications were being stored in weekly medication containers. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2024
Plan of Correction
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Administrator removed the weekly medication containers from the centrally stored location at time of visit. POC cleared.
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:Rikesha Stamps
LICENSING EVALUATOR NAME:Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 07/31/2024 05:58 PM - It Cannot Be Edited


Created By: Stephanie Martinez On 07/31/2024 at 05:03 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: SMITH ROAD ASSISTED LIVING
FACILITY NUMBER: 331881421

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87467(a)(3)
Resident Participation in Decisionmaking
(a) Prior to, or within two weeks of the resident's admission, the licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility. (3) The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident's condition, or once every 12 months, whichever occurs first. Significant changes shall include, but not be limited to occurrences specified in Section 87463, Reappraisals.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in five out of five residents (R1 - R5) who did not have a written record of care on file. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/31/2024
Plan of Correction
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Administrator stated a written record will be created for each resident in care and submit a letter of certification to the Department.

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:Rikesha Stamps
LICENSING EVALUATOR NAME:Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2024


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 07/31/2024 05:58 PM - It Cannot Be Edited


Created By: Stephanie Martinez On 07/31/2024 at 05:03 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: SMITH ROAD ASSISTED LIVING
FACILITY NUMBER: 331881421

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.39(b)
Regulations
(b) A residential care facility for the elderly that accepts or retains residents with restricted health conditions, as defined by the department, shall ensure that residents receive medical care as prescribed by the resident’s physician and contained in the resident’s service plan by appropriately skilled professionals acting within their scope of practice. An appropriately skilled professional may not be required when the resident is providing self-care, as defined by the department, and there is documentation in the resident’s service plan that the resident is capable of providing self-care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on interview and record review, the licensee did not comply with the section cited above in two out of two residents (R1 and R5) who have a restricted health condition and have no documentation on file indicating the residents can manage their own health conditions. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/07/2024
Plan of Correction
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2
3
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Administrator stated written documentation showing the residents are able to manage their own health conditions and submit proof to the Department.
Type B
Section Cited
CCR
87633(b)
Hospice Care for Terminally Ill Residents
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in one out of one residents (R6) who did not have a hospice care plan on file. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2024
Plan of Correction
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2
3
4
The Administrator contacted the hospice agency and obtained a copy of the care plan during the LPA's visit. POC cleared.
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:Rikesha Stamps
LICENSING EVALUATOR NAME:Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2024


LIC809 (FAS) - (06/04)
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