331881421-6-30-2023-18-AS-YDEO-CTAVJ3-20230630162801

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881421
Report Date: 05/22/2023
Date Signed: 06/30/2023 04:28:14 PM

Document Has Been Signed on 06/30/2023 04:28 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:	SMITH ROAD ASSISTED LIVING		FACILITY NUMBER:	331881421
ADMINISTRATOR:	LECITA, MA SATCHEL		FACILITY TYPE:	740
ADDRESS:	753 SMITH ROAD		TELEPHONE:	(951) 927-8178
CITY:	HEMET	STATE: CA	ZIP CODE:	92544
CAPACITY:	12	CENSUS: 6	DATE:	05/22/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Ma Satchel Lecita, Administrator		TIME COMPLETED:	12:00 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 9:00 AM, LPA met with Licensee/Administrator Ma Satchel Lecita and Long Zhang, Licensee. An Initial Application to operate a Residential Care for the Elderly facility (RCFE) was submitted to the Central Applications Bureau (CAB) on 1/22/23 for a total capacity of twelve (12); (5) non-ambulatory and seven (7) ambulatory residents. Fire clearance was granted on 04/17/2023. LPA Delgado observed the following: Structure: Facility was a one-story house with seven (7) resident bedrooms, three (3) resident bathrooms, living room, dining area and kitchen. There was an attached three (3) car garage in the front of the house with recently added wood beam structure to separate a part of the garage into storage rooms. Heating/Cooling System: Central heating and air conditioning system installed with two panels located in the reception area and hallway to control entire house. Bedrooms: Each resident bedroom #A, #C (shared) and #G (shared) will accommodate any non-ambulatory resident, bedrooms #B, #D (shared), #E (shared), and #F (shared) will accommodate ambulatory residents. Seven (7) resident bedrooms were adequately furnished with bed, some bedrooms missing chairs, closet, appropriate linens, adequate lighting, and an operable smoke alarm. Bathrooms: Three (3) resident bathrooms has a working toilet; toilet in #G not flushing, wash basin, and shower with an adequate supply of paper towels, toilet paper, and soap. At 10:01 AM, LPA tested the water temperatures in the resident bathrooms; room #G shower faucet is loose from wall. LPA verified water temperature was measured at 105.3 degrees Fahrenheit. (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: 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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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: SMITH ROAD ASSISTED LIVING	FACILITY NUMBER: 331881421
	VISIT DATE: 05/22/2023

NARRATIVE

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(CONTINUED FROM LIC 809)
Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots and pans were observed. Knives/sharp instruments were secured in a locked drawer located in the kitchen. There was adequate room for food storage. Several cabinets with food stored had locks and a white plastic chain that blocked access to food supply. LPA observed the stove to be operational. Refrigerator/freezer were in working condition 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 the house. Laundry detergents and cleaning supplies were observed inside laundry room away from residents.
Living/Dining room:
There was a living room with furniture and TV and Dining room with furniture for all clients.
Linens and Hygiene Supplies:
An adequate supply of linens was stored in a cabinet in the main hallway of the residence and Room #G that extra linen will be relocate to the Laundry room.
Yards/Outside:
Patio furniture and sufficient chairs were observed in the backyard. There was a gate on the South side of the property with a self-latching lock. All outdoor pathways were free of obstructions.
Emergency Phone Numbers, and Exit Plan:
Facility sketch were observed posted in the main hallway; needs to be updated to reflect the changes in the garage. Obudsman poster and Let-Us-No poster observed.
General items:
Six (6) fire extinguishers were charged; however missing inspection tags and/or receipts when purchased and located in the kitchen, (3) reception, and (2) hallway . Twelve (12) smoke alarms and two (2) carbon monoxide detectors were tested and were observed to be in working order. Windows were missing screens and/or had torn screens. Client records will be stored in a locked cabinet in the Reception area. First Aid kit with required components; no First Aid Manual observed, and locked area for medication storage 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 observed however the required 72-hour emergency food supply was not discernible from the regular food supply.

(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: 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

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: SMITH ROAD ASSISTED LIVING	FACILITY NUMBER: 331881421
	VISIT DATE: 05/22/2023

NARRATIVE

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(CONTINUED FROM LIC809C)

Pre-Licensing is incomplete and the following corrections to be resolved by 5/31/2023:

obtain a separate 72-hour emergency food supply
obtain screens for windows
obtain chairs for resident rooms
obtain a label and post for Hot water 125 degrees for kitchen sink
obtain receipts or service tags for all fire extinguishers
obtain a hard surface for bed frames
obtain Firs Aid Manual latest edition
obtain paper towel holders or dispensers for paper towels
obtain and post visiting policy
consult pest control for insects
relocate linen from Bathroom #G
repair toilet for Room #G to be able to flush
repair shower faucet; loose from wall
replace torn window screens
remove white plastic chain in kitchen
remove latches and locks for all kitchen cabinet doors except sharps and cleaning products
Kitchen needs deep cleaning for dirt buildup
Bathrooms needs deep cleaning for dirt buildup
Updated Facility sketch with CAB

An exit interview was conducted, and a copy of this report will be emailed and a receipt of confirmation will be requested.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda Delgado	TELEPHONE: (951) 203-2990
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

LIC809 (FAS) - (06/04)

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