336403710-7-20-2023-18-AS-JROO-CTWQM6-20230720121700

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336403710
Report Date: 07/20/2023
Date Signed: 07/20/2023 12:17:05 PM

Document Has Been Signed on 07/20/2023 12:17 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	MURRIETA HOME CARE		FACILITY NUMBER:	336403710
ADMINISTRATOR:	MARIA ARACELI UNDAN		FACILITY TYPE:	740
ADDRESS:	41035 CHACO CANYON ROAD		TELEPHONE:	(951) 600-1294
CITY:	MURRIETA	STATE: CA	ZIP CODE:	92562
CAPACITY:	6	CENSUS: 5	DATE:	07/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:25 AM
MET WITH:	Caregiver Arvin Valenciano		TIME COMPLETED:	12:15 PM

NARRATIVE

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On 7/20/2023, at 10:25 a.m., Licensing Program Analyst (LPA) Janette Romero arrived unannounced at the facility to conduct an annual required visit. LPA was greeted and granted entry by Caregiver, Arvin Valenciano who was informed of the purpose of visit. At the time of visit there was five (5) residents, and two (2) staff present.

The facility is approved to care for six (6) non-ambulatory residents and has a dementia program along with a hospice waiver for two (2). Facility has a bedridden fire clearance for six (6) residents. LPA toured the facility inside and out with Caregiver Valenciano. During the visit, LPA observed the following:

Kitchen: LPA observed kitchen to be clean. Food is stored in a safe and healthful manner. Utensils and dishware are sufficient for the approved capacity. LPA observed food supply met the requirement for a two-day supply of perishable food and seven-day supply of non-perishable food. Sharps are secured in a locked kitchen drawer.

Dining and Livingroom: LPA toured the dining and living/family room area. LPA observed area to be clean and furniture in good condition.

Hallway: LPA toured the hallway and observed hallway to be clean with no pathway obstruction. Carbon monoxide & smoke detector were tested and functioning properly. Fire extinguisher is charged and up to date.

Records: Staff present possess criminal background clearance and association to the facility. Administrator’s certificate expires on 10/18/2023.

Continued on LIC809-C..

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette Romero	TELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

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 07/20/2023 12:17 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MURRIETA HOME CARE	FACILITY NUMBER: 336403710
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(a)(4)

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. 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 due to descrepancies found in Medication Adminstration Record, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/31/2023
	Plan of Correction
1 2 3 4	Facility agreed to conduct staff training regarding assistance with administering medication followed by documentation in MARs log. Proof of correction will be provided to CCLD by close of business on 7/31/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 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: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette Romero	TELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MURRIETA HOME CARE	FACILITY NUMBER: 336403710
	VISIT DATE: 07/20/2023

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Continued from LIC809.

Centrally Stored Medications: LPA observed a first aid kit with required components. Medications were secured in a kitchen cabinet. LPA reviewed physical medications for the residents as well as the Medication Administration Record (MAR) used to log administration of residents’ medications. LPA discovered the MARs was not signed/noted for medication refusal from 7/15-20/2023. Caregiver Valenciano stated he assisted residents with medication for the past five days but forgot to initial the MARs. Deficiency cited.

Bedrooms: Client bedrooms were each furnished with a bed, chair, closet, clothing storage and lighting.

Bathrooms: Bathrooms have a working toilet, wash basin, and were equipped with a grab bar in the shower. The hot water temperature measured at 116- and 118-degrees Fahrenheit. The facility has clean towels, blankets, and linen, available in different colors for the residents in care.

Garage/Laundry: LPA observed laundry room and garage to be clean. Washing machine and dryer are all in good repair. Laundry detergent was observed to be secured in locked laundry room.

Yard/Outside Area: Covered patio seating is available for the residents in care. A gate/wood wall secured the entire backyard. All outdoor pathways were free of obstructions. No bodies of water were observed. There were no firearms or ammunition observed at the facility, and LPA was informed the facility will not store firearms or ammunition on the premises.

Due to discrepancies in MARs log, LPA cited a deficiency faulting the facility. Deficiency noted on LIC809-D. An exit interview was conducted, and a copy of this report was reviewed and provided to Caregiver Valenciano along with LIC809-D and Appeals Rights.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette Romero	TELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

LIC809 (FAS) - (06/04)

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