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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530121
Report Date: 10/17/2024
Date Signed: 10/17/2024 01:20:55 PM

Document Has Been Signed on 10/17/2024 01:20 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
, CA 92507
FACILITY NAME:EAGLE CREST ASSISTED LIVING HOMEFACILITY NUMBER:
335530121
ADMINISTRATOR/
DIRECTOR:		WILSON, LATONIAFACILITY TYPE:
740
ADDRESS:35111 TAVEL STTELEPHONE:
(951) 484-5960
CITY:WINCHESTERSTATE: CAZIP CODE:
92596
CAPACITY: 6CENSUS: 4DATE:
10/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:35 AM
MET WITH:Licensee/Administrator Latonia WilsonTIME VISIT/
INSPECTION COMPLETED:
01:25 PM
NARRATIVE
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On 10/17/2024 at 08:35 AM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct the required comprehensive annual inspection. LPA Brown met with a staff and was granted entry to the facility. Licensee/Administrator Latonia Wilson arrived at the facility during the visit. At the time of the visit there were two (2) staff present, and four (4) residents present.

The facility is a five (5) bedroom, three (3) bathroom home with a kitchen/dining area, living room/activity room, laundry room, garage and a backyard. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) of which three (3) can be non-ambulatory residents, two (2) can be bedridden and one (1) ambulatory resident. The facility’s approved for six (6) hospice waiver. The current census is four (4) residents. LPA Brown was accompanied by Licensee/Administrator Wilson to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 73 degrees Fahrenheit. LPA Brown 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 Brown observed sufficient furniture and lighting throughout the facility. LPA Brown measured and observed the water temperature in the residents shared bathroom to be at 111 degrees Fahrenheit. The facility is equipped with operating combined smoke detectors and carbon monoxide alarms. Fire extinguisher was also observed at the facility. Posters such as personal rights, the CCLD complaint poster, labor laws,ombudsman poster and the disaster plan were posted in a common area. ***Continuation in LIC809C ***
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 10
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
, CA 92507
FACILITY NAME: EAGLE CREST ASSISTED LIVING HOME
FACILITY NUMBER: 335530121
VISIT DATE: 10/17/2024
NARRATIVE
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During the tour of the facility, LPA Brown observed one (1) 3 qts of RugDoctor in the laundry room, not locked and accessible to residents in care. Deficiency will be issued. There was a designated storage space for resident/staff files. There is a Medicine Cabinet with the resident’s medications locked. LPA Brown observed the complete first aid kit and first aid book at the facility. In addition, LPA Brown observed no emergency supplies/kits, no emergency water maintained at the facility. Deficiency will be issued. Moreover, LPA Brown observed that the facility's not conducting the required fire and earthquake drill at least quarterly. Deficiency will be issued.

Food Service: More than seven (7) days’ supply of Non-perishable foods and more than two (2) days’ supply of perishable food supply were observed and sufficient for the number of residents in care.

Care & Supervision: The facility has an Administrator present at the facility with appropriate and enough hours to appropriately manage the facility. The facility has sufficient number of staff to provide care and supervision to the residents in care.

Record Review: LPA Brown noted the Infection Control Plan at the facility. LPA Brown reviewed three (3) resident files for admission agreements, updated medical assessments/physician reports, pre-placement appraisals, Centrally Stored Medication List and Preplacement Needs and Services plan/Care Plan. LPA Brown observed that Resident #3 (R3) does not have the required Pre-placement Needs and Services Plan/Care Plan. Deficiency will be issued. LPA Brown reviewed four (4) staff files for First Aid/CPR certification, criminal record clearance, required trainings, health screenings, tuberculosis (TB) test with TB test result. LPA Brown observed that one (1) of four (4) staff does not have the required trainings. Deficiency will be issued.

Medications/Medication Administration Record (MAR) were audited for three (3) residents, and LPA Brown observed that facility staffs are not assisting Resident #1 (R1) and Resident #2 (R2) with their self- administered medications as needed as evidenced of R1's one (1) medication was not given per R1's physician's order and R2's one (1) medication was not given per R2's physician's order. Deficiency will be issued.

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

An exit interview was conducted, and this report (LIC809), LIC809D forms, and Appeal Rights were discussed and provided to Licensee/Administrator Latonia Wilson.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
LIC809 (FAS) - (06/04)
Page: 2 of 10
Document Has Been Signed on 10/17/2024 01:20 PM - It Cannot Be Edited


Created By: Melody Brown On 10/17/2024 at 12:31 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
, CA 92507

FACILITY NAME: EAGLE CREST ASSISTED LIVING HOME
FACILITY NUMBER: 335530121

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.69(b)
Other Provisions
(b) Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Staff #4 (S4) complete the required annual/yearly eight (8) hours of in0service training on medication related issues which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/18/2024
Plan of Correction
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LIcensee stated to submit S4 proof of enrollment/certification on the required annual/yearly eight (8) hours of in0service training on medication related issues to LPA Brown on Plan of Correction (POC) due date.
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that facility staffs are assisting Resident #1 (R1) and Resident #2 (R2) with their self- administered medications as needed as evidenced of R1's one (1) medication was not given per R1's physician's order and R2's one (1) medication was not given per R2's physician's order which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/18/2024
Plan of Correction
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3
4
Licensee stated to train all staff on CCR 87465(a)(4) and conduct Medication Training on all staff and submit proof to LPA Brown on POC due date.
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
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024


LIC809 (FAS) - (06/04)
Page: 3 of 10
Document Has Been Signed on 10/17/2024 01:20 PM - It Cannot Be Edited


Created By: Melody Brown On 10/17/2024 at 12:31 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
, CA 92507

FACILITY NAME: EAGLE CREST ASSISTED LIVING HOME
FACILITY NUMBER: 335530121

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that the 3 qts bottle of RugDoctor in the Laundry Room was locked and not accessible to residents in care
which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/18/2024
Plan of Correction
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LIcensee stated to train all staff on CCR 87705(f)(1) and submit proof to LPA Brown on Plan of Correction (POC) due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024


LIC809 (FAS) - (06/04)
Page: 4 of 10
Document Has Been Signed on 10/17/2024 01:20 PM - It Cannot Be Edited


Created By: Melody Brown On 10/17/2024 at 12:31 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
, CA 92507

FACILITY NAME: EAGLE CREST ASSISTED LIVING HOME
FACILITY NUMBER: 335530121

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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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2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Staff #4 (S4) complete the required additional 20 hours annual training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/25/2024
Plan of Correction
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Licensee stated to submit proof of S4 enrollment to complete the required 20 hours annual training or certification of completed annual 20 hours training to LPA Brown on Plan of Correction (POC) due date.
Type B
Section Cited
HSC
1569.695(a)(2)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that emergency supplies/kits, and emergency water were maintained at the facility bwhich poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/25/2024
Plan of Correction
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LIcensee stated to submit proof of emergency supplies/kits and emergency water maintained at the facility to LPA Brown on POC due date.
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
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024


LIC809 (FAS) - (06/04)
Page: 5 of 10
Document Has Been Signed on 10/17/2024 01:20 PM - It Cannot Be Edited


Created By: Melody Brown On 10/17/2024 at 12:31 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
, CA 92507

FACILITY NAME: EAGLE CREST ASSISTED LIVING HOME
FACILITY NUMBER: 335530121

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(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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3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not
conducting the required fire and eathquake drill at least quarterly which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/25/2024
Plan of Correction
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Licensee stated to conduct the required fire and earthquake drill this month and at quarterly thereafter and submit proof to LPA Brown on Plan of Correction (POC) due date.
Type B
Section Cited
HSC
1569.695(e)(2)
Other Provisions
(e) A facility shall have all of the following information readily available to facility staff during an emergency: (2) An appraisal of resident needs and services plan for each resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review)], the licensee did not comply with the section cited above
by not ensuring that a Needs and Services Plan Appraisal/Care Plan for Resident #3 (R3) was completed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/25/2024
Plan of Correction
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Licensee stated to submit a copy of R3's Needs and Services Plan Appraisal/Care Plan to LPA Brown on POC due date.
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
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024


LIC809 (FAS) - (06/04)
Page: 6 of 10
Document Has Been Signed on 10/17/2024 01:20 PM - It Cannot Be Edited


Created By: Melody Brown On 10/17/2024 at 12:31 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
, CA 92507

FACILITY NAME: EAGLE CREST ASSISTED LIVING HOME
FACILITY NUMBER: 335530121

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by allowing Resident #3 (R3) to have a half bed rail and not ensuring that Resident #3 (R3) has a written order from R3 physician indicating the need for half bed rail for mobility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/25/2024
Plan of Correction
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2
3
4
Licensee stated to obtain a written order from R3 physician indicating the need for half bed rail for mobility and submit a copy to LPA Brown on Plan of Correction (POC) due date.
Section Cited
Deficient Practice Statement
1
2
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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024


LIC809 (FAS) - (06/04)
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