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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336400004
Report Date: 02/08/2024
Date Signed: 02/08/2024 03:33:36 PM


Document Has Been Signed on 02/08/2024 03:33 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:MAYFLOWER GUEST HOME IIFACILITY NUMBER:
336400004
ADMINISTRATOR:CRISTINA FAJARDOFACILITY TYPE:
740
ADDRESS:11287 NORWOOD AVE.TELEPHONE:
(951) 351-9074
CITY:RIVERSIDESTATE: CAZIP CODE:
92505
CAPACITY:15CENSUS: 15DATE:
02/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator Cristina FajardoTIME COMPLETED:
03:45 PM
NARRATIVE
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On 02/08/2023 at 09:30 AM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Brown met with a staff and was granted entry to the facility. Administrator Cristina Fajardo was contacted and arrived at the facility during the visit. At the time of the visit there were fifteen (15) residents and six (6) staff present.

The facility is an eleven (11) bedroom, and four (4) bathroom home with a kitchen/dining area, living room/activity room. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of fifteen (15) ambulatory residents and the current census is fifteen (15) residents. LPA Brown was accompanied by Administrator Fajardo 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 passageway but LPA Brown observed obstructions to outdoor passageways as piles of wood were observed with visible nails hanging located at the backyard of the home. Deficiency will be issued. The facility is maintained at a comfortable temperature. 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. However, LPA Brown observed no reading lamps on Room # 4, Room #5, Room #2, Room #9 and Room #11. Also, LPA Brown observed no chairs in Room # 8, Room #9 and Room #10. Deficiency will be issued. LPA Brown measured and observed the water temperature in the bathroom to be at 108 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Fire extinguishers were also observed at the facility. ***Continuation in LIC809C ***
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2024
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 17


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: MAYFLOWER GUEST HOME II
FACILITY NUMBER: 336400004
VISIT DATE: 02/08/2024
NARRATIVE
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Posters such as labor laws, and the disaster plan were posted in a common area, but LPA Brown observed the personal rights, the CCLD complaint poster and Ombudsman poster were not posted in a common area. Deficiency will be issued.

Cleaning supplies, chemicals and other dangerous items were observed not locked at the back area of the facility, making it accessible to residents in care. Deficiency will be issued. Also, LPA Brown observed no activity schedule posted at the facility. Deficiency will be issued. Furthermore, LPA Brown observed no night lights and emergency lightning maintained at the facility. 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 a complete first aid kit and first aid book at the facility.

Food Service: More than seven (7) days’ supply of Non-perishable foods and more than three (3) 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 in 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 reviewed three (3) resident files for admission agreements, physician reports, pre-placement appraisals, functional capabilities and needs and services plans. LPA Brown observed that Resident #1 (R1), Resident #2 (R2) and Resident #3 (R3) do not have the required pre-placement appraisals, functional capabilities and needs and services plan. Deficiencies will be issued. LPA Brown reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA Brown found that Staff #2 (S2), and Staff #5 (S5) do not have completed Health Screening report with Tuberculosis (TB) Result maintained in their facility file and no required annual trainings were completed by S2 and S5. Also, LPA Brown observed that S2 and S5 do not have the required contiunation/annual training maintained on S2 and S5 facility file and S5 does not have the required initial training. Deficiencies will be issued. Moreover, three (3) residents medications were audited and per review of their Medication Administration Record (MAR), LPA Brown observed two (2) medications for Resident # 1 (R1) were dispensed but R1's MAR was not updated and one (1) medication was dispensed for Resident #3 (R3) and R3’s MAR is not updated. 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, LIC9102 and Appeal Rights were discussed and provided to Administrator Cristina Fajardo.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024
LIC809 (FAS) - (06/04)
Page: 2 of 17
Document Has Been Signed on 02/08/2024 03:33 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: MAYFLOWER GUEST HOME II
FACILITY NUMBER: 336400004

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)(1)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

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 locking the storage area for cleaning solutions, chemicals and sharp gardening tools located at the back area of the facility, making it accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/09/2024
Plan of Correction
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Licensee locked the storage space and the sharp gardening tools were locked as well during the visit.
Licensee stated to train all staff on CCR 87309(a)(1) and submit proof of Staff Training Log to LPA Brown at Plan of Correction (POC) due date.
Type A
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not updating R1 and R3 Medication Administration Record (MAR) after dispensing their medications which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/09/2024
Plan of Correction
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2
3
4
Licensee stated to train all staff on CCR 87465(a)(6) and submit proof of Staff Training Log to LPA Brown at Plan of Correction 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 MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2024
LIC809 (FAS) - (06/04)
Page: 3 of 17


Document Has Been Signed on 02/08/2024 03:33 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: MAYFLOWER GUEST HOME II
FACILITY NUMBER: 336400004

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(h)
Maintenance and Operation
(h) Emergency lighting shall be maintained. At a minimum this shall include flashlights, or other battery powered lighting, readily available in appropriate areas accessible to residents and staff. Open-flame lights shall not be used.

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 having an emergency lighting maintained at the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/19/2024
Plan of Correction
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Licensee stated to obtain or purchase emergency lighting for the facility and submit proof to LPA Brown at Plan of Correction (POC) due date.
Type B
Section Cited
CCR
87307(a)(3)(B)
Personal Accommodations and Services
(B) Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers.

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 having lamps on no reading lamps on Room # 4, Room #5, Room #2, Room #9 and Room #11. Also, LPA Brown observed no chairs in Room # 8, Room #9 and Room #10 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/19/2024
Plan of Correction
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Licensee stated to provide lamps on Room # 4, Room #5, Room #2, Room #9 and Room #11 and chairs on Room # 8, Room #9 and Room #10 and submit proof to LPA Brown at 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 MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2024
LIC809 (FAS) - (06/04)
Page: 4 of 17


Document Has Been Signed on 02/08/2024 03:33 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: MAYFLOWER GUEST HOME II
FACILITY NUMBER: 336400004

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(5)
Personal Accommodations and Services
(5) Night lights shall be maintained in hallways and passages to nonprivate bathrooms.

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 having night lights maintained in hallways and passageways to nonprivate bathrooms which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/19/2024
Plan of Correction
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Licensee stated to obtain/purchase night lights for the facility and submit proof to LPA Brown at Plan of Correction (POC) due date.
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

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 having the outdoor passageway free of obstructions which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/19/2024
Plan of Correction
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Licensee stated to remove the pile of woods with sharp nails hanging out at the backyard of the facility and submit proof to LPA Brown at 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 MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2024
LIC809 (FAS) - (06/04)
Page: 5 of 17


Document Has Been Signed on 02/08/2024 03:33 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: MAYFLOWER GUEST HOME II
FACILITY NUMBER: 336400004

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(12)
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: (12) Hazardous health conditions documents as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not having Staff #2 (S2) and Staff #5 (S5) have a complete Health Screening Report with Tuberculosis (TB) Test Result maintained in their facility file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/19/2024
Plan of Correction
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Licensee stated to submit a copy of completed Health Screening Report with TB Test Result for S2 and S5 and submit proof to LPA Brown at Plan of Correction (POC) due date.
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
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not having S5 complete the required 10 hours of initial training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/19/2024
Plan of Correction
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2
3
4
Licensee stated to have S5 complete the required 10 hours of initial training and submit proof to LPA Brown at 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 MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2024
LIC809 (FAS) - (06/04)
Page: 6 of 17


Document Has Been Signed on 02/08/2024 03:33 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: MAYFLOWER GUEST HOME II
FACILITY NUMBER: 336400004

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.267(d)
Resident's Bill of Rights
(d) The licensee shall provide initial and ongoing training for all members of its staff to ensure that residents’ rights are fully respected and implemented.

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 having the required ongoing/annual training for Staff #2 (S2) and Staff #5 (S5) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/19/2024
Plan of Correction
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2
3
4
Licensee stated to have all staff complete the required ongoing/annual training and submit proof to LPA Brown at Plan of Correction (POC) due date.
Type B
Section Cited
CCR
87219(a)(1)
Planned Activities
(a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. The activities made available shall include: (1) Socialization, achieved through activities such as group discussion and conversation, recreation, arts, crafts, music, and care of pets.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record revie], the licensee did not comply with the section cited above by not having an activity calendar available and posted at the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/19/2024
Plan of Correction
1
2
3
4
Licensee stated to aomplete and submit a copy of the facility's Activity Calendar to LPA Brown at 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 MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2024
LIC809 (FAS) - (06/04)
Page: 7 of 17


Document Has Been Signed on 02/08/2024 03:33 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: MAYFLOWER GUEST HOME II
FACILITY NUMBER: 336400004

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87456(a)(2)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not performing a Pre-Admission Appraisal for Resident #1 (R1), Resident #2 (R2) and Resident #3 (R3) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/26/2024
Plan of Correction
1
2
3
4
Licensee stated to submit completed Pre-Admission Appraisal for R1, R2 and R3 to LPA Brown at Plan of Correction (POC) due date.
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not completing the required Needs and Services Plan for R1, R2 and R3 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/26/2024
Plan of Correction
1
2
3
4
Licensee stated to submit copies of completed Needs and Services Plan for R1, R2 and R3 to LPA Brown at Plan of Correction (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 MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2024
LIC809 (FAS) - (06/04)
Page: 8 of 17


Document Has Been Signed on 02/08/2024 03:33 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: MAYFLOWER GUEST HOME II
FACILITY NUMBER: 336400004

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87457(c)(1)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. (1) The appraisal shall include, at a minimum, an evaluation of the prospective resident's functional capabilities, mental condition and an evaluation of social factors as specified in Sections 87459, Functional Capabilities and 87462, Social Factors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review], the licensee did not comply with the section cited above by not completing the required Functional Capabilities Assessment for R1, R2 and R3 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/26/2024
Plan of Correction
1
2
3
4
Licensee stated to complete and submit copies of R1, R2 and R3 Functional Capabilities Assessment to LPA Brown at Plan of Correction (POC) due date.
Type B
Section Cited
HSC
1569.695(b)
Other Provisions
(b) A facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and (record review, the licensee did not comply with the section cited above by not providing staff training on Emergency or Disaster which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/19/2024
Plan of Correction
1
2
3
4
Licensee stated to train all staff on Emergency and Disiater and submit proof of Training Log to LPA Brown at 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 MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2024
LIC809 (FAS) - (06/04)
Page: 9 of 17


Document Has Been Signed on 02/08/2024 03:33 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: MAYFLOWER GUEST HOME II
FACILITY NUMBER: 336400004

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/08/2024

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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Based on observation, interview and record review, the licensee did not comply with the section cited above by not having a recent Fire drill conducted at the facility and not having earthquake drill conducted at the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/19/2024
Plan of Correction
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Licensee stated to conduct Fire and Earthquake Drill on all shifts and submit proof to LPA Brown at 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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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 MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2024
LIC809 (FAS) - (06/04)
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