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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881477
Report Date: 01/24/2025
Date Signed: 01/27/2025 08:16:32 AM

Document Has Been Signed on 01/27/2025 08:16 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:LIVING WATER ELDERCAREFACILITY NUMBER:
331881477
ADMINISTRATOR/
DIRECTOR:		MIKENAS, ANNIE JANEFACILITY TYPE:
740
ADDRESS:30210 POWDERHORN LANETELEPHONE:
(951) 837-0525
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY: 6CENSUS: 5DATE:
01/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Allen CaliboTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Abdoulaye Zerbo conducted an unannounced visit for a required annual inspection. The LPA was greeted by Caregiver Allen Calibo, notified him of the purpose for the visit and was allowed to enter the facility to conduct the inspection.

Facility Overview: The facility is a single story building with four (4) residents bedrooms, one(1) staff room two(2) bathrooms, a living room, a kitchen area, a garage and a shed There is no gated pool and there are no firearms on the premises.

Infection Control: LPA observed that hygiene and cleaning supplies were available for regular facility maintenance. The facility’s infection control plan was reviewed and found to meet department requirements.

Physical Plant: The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. Laundry equipment was in good working condition. Sharp and dangerous objects were securely locked in the kitchen inaccessible to residents. The smoke detector and carbon monoxide detector were operational. LPA observed fire extinguishers not to be in compliance with the department requirements with an expiration date of August 22, 2024. A citation will be issued.The water temperature was tested within regulations.

Continued 809-C......

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2025
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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Document Has Been Signed on 01/27/2025 08:16 AM - It Cannot Be Edited


Created By: Abdoulaye Zerbo On 01/24/2025 at 10:41 AM
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: LIVING WATER ELDERCARE
FACILITY NUMBER: 331881477

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interviews ,and record review, the licensee did not comply with the section cited above in [1] out of [1] Aministrator's file not available for review, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/24/2025
Plan of Correction
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Licensee will sent proof of the file with all the required documents to LPA by POC due date
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2025


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 01/27/2025 08:16 AM - It Cannot Be Edited


Created By: Abdoulaye Zerbo On 01/24/2025 at 10:41 AM
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: LIVING WATER ELDERCARE
FACILITY NUMBER: 331881477

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
FIRE SAFETY: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshall for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based observation and interview, the licensee did not comply with the section cited above in one fire extinguisher observed last inspected on 08-22-2023 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/25/2025
Plan of Correction
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Licensee will sent proof of correction to LPA by POC due date
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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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:Rikesha Stamps
LICENSING EVALUATOR NAME:Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 01/27/2025 08:16 AM - It Cannot Be Edited


Created By: Abdoulaye Zerbo On 01/24/2025 at 10:54 AM
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: LIVING WATER ELDERCARE
FACILITY NUMBER: 331881477

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the facility did not have an updated record of drills conducted with staff that include the type of drill, date of drill and staff names who participated in the drill. The facility did not comply with the section cited above in [5] out of [5] persons which poses/posed a potential health, safety or personal rights risk to persons in care
POC Due Date: 02/24/2025
Plan of Correction
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Licensee will conduct a drill and list the names of the staff who particiapated and send proof to LPA by POC due date
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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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:Rikesha Stamps
LICENSING EVALUATOR NAME:Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2025


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: LIVING WATER ELDERCARE
FACILITY NUMBER: 331881477
VISIT DATE: 01/24/2025
NARRATIVE
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Care & Supervision/Administration: Adequate staff were present to supervise clients during the visit. The administrator holds a current administrator’s certificate with expiration date of July 01, 2025


Record Review and Resident/Staff Files: LPAs reviewed files for two(2) staff members, confirming criminal clearances, updated training, and CPR/First Aid certification. Five (5) residents' files were reviewed. LPAs observed first aid kit to be locked and inaccessible to the residents in care. The residents and staff files were kept in a locked cabinet in the hallway and inaccessible to unauthorized individuals

Health-Related Services/Incidental Medical Services: All residents' medications were securely locked in a cabinet and located in the hallway. LPA reviewed medications for five residents, confirming that all medications were listed and accounted for.

Disaster Preparedness: LPAs reviewed the facility’s emergency and disaster plan. LPA did not observe any records of the last drill conducted at the facility. A citation will be issued. All facility exits were clear of obstructions.


An exit interview was conducted, during which this report was reviewed, and a copy was provided to caregiver Allen Calibo along with the appeal rights.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025
LIC809 (FAS) - (06/04)
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