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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336405788
Report Date: 08/23/2022
Date Signed: 08/23/2022 05:18:29 PM


Document Has Been Signed on 08/23/2022 05:18 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
RIVERSIDE, CA 92507



FACILITY NAME:CHICAGO HOPE ASSISTED LIVINGFACILITY NUMBER:
336405788
ADMINISTRATOR:KAREN COCCHIAROFACILITY TYPE:
740
ADDRESS:25858 NEW CHICAGOTELEPHONE:
(951) 663-8514
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY:6CENSUS: 6DATE:
08/23/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Deanna Maegillivary - CaregiverTIME COMPLETED:
05:30 PM
NARRATIVE
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During Licensing Program Analyst (LPA) Crystal Colvin's inspection at the facility for a complaint investigation (#18-AS-20220819153930), LPA Colvin observed following additional violations:
  • Admissions Agreement - LPA Colvin observed that resident (R1) has been living at the facility since 8/13/22 and does not have a completed Admissions Agreement. This paperwork has been the source of confusion for R1 and R1's representative, and has been an ongoing issue. Deficiency cited.

  • Personal Rights - Since R1's Admissions Agreement is not completed, there has been confusion over what the facility rules are and it was reported to LPA Colvin during their investigation that some staff members institute a curfew for residents at 8pm, while others do not. Licensee/Administrator denies that there is a curfew. R1 has not signed acknowledgement of the facility rules (in the Admissions Agreement) which would make these rules clear to R1 and their representative. Deficiency cited.

  • Licensing Fees - The Licensee is behind in their licensing fees and currently owes Licensing $742.00 for the licensing fees for the year 2021 and subsequent late fee. Annual fee for this facility was due September 2021. Deficiency cited.

  • Plan of Operation - LPA Colvin observed what appeared to be a closet, pantry, or addition (one wall does not reach the ceiling) to be in use as a staff room. The facility sketch on file with Licensing and the facility sketch posted in the facility does not reflect this room. LPA Colvin additionally observed Admissions Agreement is different than what Licensing has on file. Deficiency cited.


Due to observations made by LPA Colvin, the facility was cited and deficiencies listed on LIC809D pages. An exit interview was conducted and a copy of this report, LCI809D, and appeal rights was provided.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2022
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 08/23/2022 05:18 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
RIVERSIDE, CA 92507


FACILITY NAME: CHICAGO HOPE ASSISTED LIVING
FACILITY NUMBER: 336405788

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/02/2022
Section Cited

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Admission Agreements: (c) Admission agreements shall be signed and dated... no later than seven days following admission.... This requirement was not met as evidenced by:
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Based on record review, the Licensee did not comply with the above regulation with one resident (R1). LPA Colvin observed that R1 has been in the facility for 10 days but does not have a signed Admissions Agreement. This is a potential personal rights violation of R1.
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Type B
09/02/2022
Section Cited

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Additional Personal Rights of Residents in Privately Operated Facilities : (a) In addition to the rights listed ...residents in ...facilities...shall have all of the following personal rights:(11) To be fully informed, prior to or at the time of admission, of all rules... This requirement was not met as evidenced by:
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Based on interviews and record review, the Licensee did not comply with the above regulation with one resident (R1). LPA Colvin observed that R1 did not have signed Admissions Agreement and interviews revealed confusion regarding house rules. This is a potential personal rights violation of R1.
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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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 08/23/2022 05:18 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
RIVERSIDE, CA 92507


FACILITY NAME: CHICAGO HOPE ASSISTED LIVING
FACILITY NUMBER: 336405788

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/02/2022
Section Cited

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Fees for license or applications; use of revenues; collected; denial or forfeiture: (e) The failure of an applicant for licensure or a licensee to pay all applicable and accrued fees and civil penalties shall constitute grounds for denial or forfeiture of a license. This requirement was not met by:
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Based on record review, the Licensee did not comply with the above Health & Safety Code with licensing fees ($742 total). LPA Colvin observed that the facility past due licensing fees for annual fees as well as late fee for 2021. This is a potential safety risk to residents in care.
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Type B
09/02/2022
Section Cited

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Plan of Operation: (a) Each facility shall have and maintain a current, written definitive plan of operation... Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval... This requirement was not met as evidenced by:
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Based on record review and observations, the Licensee did not comply with the above regulation with two aspects of the facility. LPA Colvin observed staff room not to be noted in the facility sketch. Additionally, Admissions Agreement currently in use is not on file with Licensing. This is a potential safety concern.
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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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3