<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336402994
Report Date: 09/29/2023
Date Signed: 09/29/2023 02:21:34 PM


Document Has Been Signed on 09/29/2023 02:21 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:LIFESTYLE HOME CAREFACILITY NUMBER:
336402994
ADMINISTRATOR:MARY MATEASFACILITY TYPE:
740
ADDRESS:5377 CAROL WAYTELEPHONE:
(951) 684-5833
CITY:RIVERSIDESTATE: CAZIP CODE:
92509
CAPACITY:6CENSUS: 3DATE:
09/29/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Licensee/Administrator Mary Mateas and Steven MateasTIME COMPLETED:
02:25 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
On 09/29/2023 at 01:00 PM, Licensing Program Analysts (LPAs) Melody Brown and Bianca Wolcott met with Licensee/Administrator Mary Mateas and Steven Mateas at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office to initiate a Case Management Office Visit. LPAs Brown and Wolcott explained the purpose of the requested Office Visit. The investigation consisted of observation, interviews and a review of pertinent documentation.

During the Inland Regional Center (IRC) facility visit on 04/25/2022, IRC staff reported that Staff 2 (S2) has not received Direct Support Professional (DSP) – I certification which should have been obtained 01/31/2020 and Staff 3 (S3) has not received the required Direct Support Professional (DSP) – II certification which should have been obtained 04/30/2022. LPA Brown will be issuing a citation for this deficiency as this poses immediate risk to residents in care.

In addition, IRC staff reported that during their visit, it was observed that no Physician Oder on file for both “Calmoseptine” and “Neosporin” for Resident 1 (R1) and its administration were not recorded on the Medication Administration Record (MAR). Moreover, during the IRC Visit, they observed that there’s no Physician Order, Medical Documentation or Plan on file to support that the facility staff were required to assist with R1’s glucose testing and monitoring. Also, per IRC’s review of documents, the administration of glucose testing was not recorded in MAR and no documentation was available to support that the S2 or S3 received training by licensed professional for glucose testing. IRC staff also observed during the visit that there is a prescription on file at the facility for R1 to take Ensure or Glucerna one (1) can twice per day, but it was also observed that the administration of Ensure or Glucerna is not being documented in the MAR. LPA Brown will be issuing a citation for these deficiencies as this poses immediate risk to residents in care.

An exit interview was conducted where this report (LIC809), LIC80D and Appeal Rights were discussed and provided to Licensee/Administrator Mary Mateas and staff Steven Mateas.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2023
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 09/29/2023 02:21 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: LIFESTYLE HOME CARE
FACILITY NUMBER: 336402994

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/30/2023
Section Cited
CCR
87411(c)(2)(B)

1
2
3
4
5
6
7
87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual... (2) This training shall be...(B) Importance and techniques of personal care... This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee stated to submit Proof of Required Trainings of all staff to LPA Brown by POC due date.
Licensee stated to submit a Signed Statement of Understanding on CCR 87411(c)(2)(B) by POC due date.

8
9
10
11
12
13
14
Based on observations, interviews and record review, the Licensee did not comply with section cited above by having S2 and S3 worked at the facility without the required initial/annual training which poses immediate health, safety, and personal rights risk to resident in care.
8
9
10
11
12
13
14
Type A
09/30/2023
Section Cited
CCR87465(h)(6)

1
2
3
4
5
6
7
87465 Incidental Medical and Dental Care(h) The following requirements shall apply to medications...(6) The licensee shall be responsible for assuring that a record... This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee stated to train all staff on CCR 87465(h)(6) and submit Training Log to LPA Brown by POC due date.
Licensee stated to submit Signed Statement of Understanding on CCR87465(h)(6) to LPA Brown by POC due date.

8
9
10
11
12
13
14
Based on observations, interviews and record review, the Licensee did not comply with section cited above by not documenting in R1's Medication Administration Record (MAR) the administration of Calmoseptine and Neosporin, the administration of glucose testing was not recorded in MAR and Ensure or Glucerna per prescription issued which poses immediate health, safety and personal rights risk to resident in care.

8
9
10
11
12
13
14
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: 09/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 09/29/2023 02:21 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: LIFESTYLE HOME CARE
FACILITY NUMBER: 336402994

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/30/2023
Section Cited
CCR
87628(a)

1
2
3
4
5
6
7
87628 Diabetes (a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee stated to train all staff on CCR 87628(a) and will submit Training Log to LPA Brown by POC due date.
Licensee stated to not allow staffs to perform blood glucose testing to residents and will only allow appropriately skilled professional to perform blood glucose check and will submit signed Statement of Understanding on CCR 87628(a) to LPA Brown by POC due date.

8
9
10
11
12
13
14
Based on interview and records review, the Licensee did not comply with the section cited above by allowing Staff #2 (S2) to perform blood glucose testing to Resident #1 (R1) which pose immediate health, safety and personal rights risks to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 09/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3