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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336402166
Report Date: 04/14/2022
Date Signed: 04/14/2022 09:51:10 AM


Document Has Been Signed on 04/14/2022 09:51 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:JMP CARE HOMEFACILITY NUMBER:
336402166
ADMINISTRATOR:EMELITA M. PRICEFACILITY TYPE:
740
ADDRESS:2771 CAMBRIDGE AVENUETELEPHONE:
(951) 766-5370
CITY:HEMETSTATE: CAZIP CODE:
92545
CAPACITY:6CENSUS: 2DATE:
04/14/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Emelita PriceTIME COMPLETED:
09:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Stephanie Williams made an unannounced visit to the facility in order to conduct a case management visit. LPA Williams identified herself to Administrator, Emelita Price who was also informed of the purpose of the visit.

On 9/30/2020, LPA Williams initiated a complaint investigation (Complaint Control #18-AS-20200928142900) and advised the Administrator that the investigation would be forwarded to the Department's Investigation Branch (IB). Upon completion of the investigation, Department staff identified that the facility had several violations that were not addressed in Complaint Control #18-AS-20200928142900. The following information was taken from the Investigative Case Report (RD #1820-09148):
  • Resident #1 (R1) experienced multiple falls while residing at the facility. A Needs & Services Plan dated 6/24/20, indicated that R1 was "subject to fall." However, the facility did not have a specific plan in place to prevent falls.
  • It was identified that R1 experienced several falls while residing at the facility; however, there was no evidence that the facility reported those falls appropriately. Staff #1 (S1) indicated to Department staff that they do not remember making the reports and they most likely did not report the falls.
  • According to medical records, R1 was "covered" in bed bugs upon arriving to the hospital on 9/17/20.

See deficiencies cited on LIC 809-D. An exit interview was conducted where this report was discussed and a copy was provided to the Administrator at the conclusion of the visit.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022
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 3


Document Has Been Signed on 04/14/2022 09:51 AM - 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
RIVERSIDE, CA 92507


FACILITY NAME: JMP CARE HOME
FACILITY NUMBER: 336402166

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/15/2022
Section Cited

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87705 Care of Persons with Dementia Licensees... ensuring the following: (5) shall include a reassessment of the resident’s dementia care... (A).. dementia care needs have changed, corresponding changes shall be made in the care and supervision provided to that resident. This requirement has not been met as evidenced by:
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Based on records review and interviews, the licensee did not ensure that corresponding changes were made to the care and supervision of R1. This is an immediate health and safety risk to residents in care.
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Type B
04/21/2022
Section Cited

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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (D) Any incident which threatens the welfare, safety or health of any resident, ...this requirement has not been met as evidenced by:
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Based on records review and interviews, the licensee did not ensure that reports regarding R1's fall, which resulted in serious injuries, were sent to the Department appropriately. This is a potential health and safety risk to residents in care.
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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) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 04/14/2022 09:51 AM - 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
RIVERSIDE, CA 92507


FACILITY NAME: JMP CARE HOME
FACILITY NUMBER: 336402166

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/21/2022
Section Cited

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87466 Observation of the Resident -
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social ... When changes such as unusual weight gains or losses or deterioration of mental ability or a physical . This requirement has not been met as evidenced by:
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Based on records review and interviews, the licensee did not ensure that R1 was regularly observed for changes in physical condition. This is a potential health and safety risk to residents in care.
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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) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022
LIC809 (FAS) - (06/04)
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