335530049-1-17-2024-56-AS-RGAR-CZKV7K-20240117151116

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 335530049
Report Date: 01/17/2024
Date Signed: 01/17/2024 03:11:23 PM

Document Has Been Signed on 01/17/2024 03:11 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	OC HOME OF LAKE ELSINORE 1		FACILITY NUMBER:	335530049
ADMINISTRATOR:	ANGELES, LOIDA		FACILITY TYPE:	740
ADDRESS:	36785 BRAKEN WAY		TELEPHONE:	(949) 202-8908
CITY:	LAKE ELSINORE	STATE: CA	ZIP CODE:	92532
CAPACITY:	6	CENSUS: 5	DATE:	01/17/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Loida Angeles- Administrator		TIME COMPLETED:	03:20 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) Ryan Gardner made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Caregiver Edelyn Dinjotian and was granted entry to the facility. Administrator Loida Angeles was phoned and arrived at the facility during the inspection. The facility is a Residential Care Facility for the Elderly (RCFE) licensed for a capacity of six (6) non-ambulatory residents, two (2) residents may be bedridden. The current census is five (5) residents. LPA was accompanied by Caregiver Edelyn Dinjotian to conduct a general overall inspection, which included, but was not limited to, the following: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to interior and exterior passageways. The facility is maintained at a comfortable temperature. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperature in the bathrooms to be at 110 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Postings such as the facility license, personal rights, the CCL complaint poster, labor laws, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident files and staff files. Medications are kept inside the cabinet in the kitchen inaccessible to residents. LPA found that the resident’s medications were removed out of their originally received prescription containers and were being stored plastic containers. The facility will be issued a deficiency for not storing the resident’s medications in the original prescription containers. Non-perishable and perishable food supply is sufficient for the residents in care. The facility does not have sufficient care staff for coverage 24 hours a day, 7 days a week.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024

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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Document Has Been Signed on 01/17/2024 03:11 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: OC HOME OF LAKE ELSINORE 1	FACILITY NUMBER: 335530049
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

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
1 2 3 4	This requirement is not met as evidenced based on observation and interview, the licensee did not comply with the section cited above evidenced by removing the resident’s medications out of their originally received prescription containers and storing the resident’s medications in plastic containers which poses an immediate health, safety, or personal rights risk to persons in care.
	POC Due Date: 01/18/2024
	Plan of Correction
1 2 3 4	The licensee has agreed to read regulation 87465 entirely and send LPA a statement of understanding that the regulation was read and understood. The licensee has agreed that moving forward the resident’s medications will be stored in the original received prescription containers. The licensee has agreed to conduct a medication training with the staff and send LPA proof of attendance. POC is due by 1/18/2024.

Type A

Section Cited

CCR

87705(c)(4)(A)

87705 Care of Persons with Dementia (c)Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. (A) In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal or observation to require awake night supervision. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	This requirement is not met as evidenced based on interview, the licensee did not comply with the section cited above evidenced by not staffing an awake staff at night to care for the residents which poses an immediate health, safety, or personal rights risk to persons in care.
	POC Due Date: 01/18/2024
	Plan of Correction
1 2 3 4	The licensee has agreed to read regulation 87705 entirely and send LPA a statement of understanding that the regulation was read and understood. The licensee has agreed to send LPA a plan and a staff schedule for an awake night staff. POC is due by 1/18/2024.

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: Efren Malagon	TELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024

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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: OC HOME OF LAKE ELSINORE 1	FACILITY NUMBER: 335530049
	VISIT DATE: 01/17/2024

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The facility has two (2) residents (R2 & R3) in care with a condition that requires an awake staff to care for the residents. LPA was informed by Staff S1 and Staff S2 that the staff does not stay awake at night. The staff is on call during the night if the residents call for help. The facility will be issued a deficiency for not staffing an awake staff at night.

LPA reviewed five (5) residents files for admission agreements, updated physician reports, and needs and services plans. LPA reviewed two (2) staff files for First Aid/CPR certifications, criminal record clearances, trainings, and health screenings.

Based on the observations made during today’s visit, two (2) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809), LIC809D, and LIC811 were discussed and provided to Administrator Loida Angeles, along with a copy of the appeal rights.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024

LIC809 (FAS) - (06/04)

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