336405788-11-9-2023-18-AS-CNWE-CXEQZM-20231109113657

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336405788
Report Date: 11/09/2023
Date Signed: 11/09/2023 11:37:01 AM

Document Has Been Signed on 11/09/2023 11:37 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	PUTTERS LANE ASSISTED LIVING		FACILITY NUMBER:	336405788
ADMINISTRATOR:	KAREN COCCHIARO		FACILITY TYPE:	740
ADDRESS:	25858 NEW CHICAGO		TELEPHONE:	(951) 663-8514
CITY:	HEMET	STATE: CA	ZIP CODE:	92544
CAPACITY:	6	CENSUS: 5	DATE:	11/09/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Karen Cocchiaro, Licensee		TIME COMPLETED:	11:45 AM

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On 11/9/2023, Licensing Program Analyst (LPA) Chinwe Nwogene arrived unannounced at the facility to conduct an annual inspection. LPA Nwogene was greeted and granted entry by Caregiver, Ramona Carmona. LPA also met with Licensee/ Administrator, Karen Cocchiaro who was informed of the purpose of visit. At the time of visit there was 1 staff and 5 residents present. LPA toured the facility inside and out with Karen Cocchiaro.

Tour included:

Kitchen; LPA toured the kitchen and observed kitchen to be clean. Food is stored in a safe and healthful manner. Utensils and dishware are sufficient for the capacity. The refrigerator and stove are in working order. Sharps are stored in a locked medication cart located in the dining, available only to authorized individuals. Trash cans has tight-fitting lids. Dishwasher is used to clean and sanitize dishes. All need appliances were present and shown to be in working condition and clean. The fridge was measured at 33 degrees Fahrenheit and Freezer was measures at 0 degrees Fahrenheit.

Dining and Livingroom; LPA toured the dinning and Livingroom area. LPA observed area to be clean and furnitures in good condition. Temperature was 71 degrees Fahrenheit.

Hallway; LPA toured the hallway and observed hallway to be clean with no pathway obstruction. LPA inspected the fire extinguisher and found it to be in compliance and fully charged. Carbon monoxide & smoke detector were tested and functioning properly. LPA observed additional linens and hygiene items.

Medications; LPA observed medications were labeled and stored in separate bins inside of a locked medication cabinet and are distributed according to physician orders. The first aid kit was complete.

Continue of LIC809-C

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Chinwe Nwogene	TELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PUTTERS LANE ASSISTED LIVING	FACILITY NUMBER: 336405788
	VISIT DATE: 11/09/2023

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Continued from LIC809.

Bathroom; LPA toured hall bathroom and observed bathroom to be clean and equipped with grab bar and non-skid floor. There is also a good number of personal toiletries available for the residents in care. The hot water measured at 115 degrees Fahrenheit

Bedroom; LPA toured four #4 out of #4 residents bedroom and observed bedrooms to be clean and furnished according to regulation, which includes proper furniture, dressers, chairs and lighting. Night lights were maintained throughout the facility. Resident #1 bedroom has a private bathroom. LPA observed bathroom to be clean and hot water was measured at 115 degrees Fahrenheit.

Garage; LPA tour the garage and observed garage to be clean.

Laundry; Cleaning supplies are stored away in the laundry room, inaccessible to clients, washing machine and dryer are all in good repair and sufficient for census.

Backyard; LPA toured the backyard and observed backyard to be clean and furnitures in good condition. The backyard was free from obstruction and the side gates remain unlocked. No bodies of water were observed.

Food Services: There are seven days non-perishable and two days of perishable food supply present, and all food was properly stored and available to residents. Fridge and freezer are larg enough to accommodate required perishable foods.

Records: All staff present have a criminal record clearance in file and are confirmed as being associated with the facility. Three staff and three residents' records were reviewed. All required postings, including COVID’s postings, were posted near the entryway and throughout the facility. The administrator certificate expired on 6/28/2023. Karen Cocchiaro informed LPA that Administrator renewal packet has been sent to the department but haven’t received the administrator certificate yet.

Interview; Two staff and three residents were interviewed.

No deficiencies noted at the time of visit. An exit interview was conducted, and a copy of this report was reviewed and provided to Karen Cocchiaro.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Chinwe Nwogene	TELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

LIC809 (FAS) - (06/04)

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