336407790-10-13-2022-56-AS-RGAR-CK6QV4-20221013122943

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336407790
Report Date: 10/13/2022
Date Signed: 10/13/2022 12:30:06 PM

Document Has Been Signed on 10/13/2022 12:30 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:	HERITAGE RESIDENTIAL CARE		FACILITY NUMBER:	336407790
ADMINISTRATOR:	MARIA ARACELI UNDAN		FACILITY TYPE:	740
ADDRESS:	20975 MARIPOSA ROAD		TELEPHONE:	(951) 245-0892
CITY:	LAKE ELSINORE	STATE: CA	ZIP CODE:	92530
CAPACITY:	6	CENSUS: 5	DATE:	10/13/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:54 AM
MET WITH:	Alexander Angulo- Caregiver		TIME COMPLETED:	12:39 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	Licensing Program Analysts (LPAs) Ryan Gardner and Victoria Chitigian made an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. LPAs met with Caregiver Alexander Angulo and was granted entry to the facility. At the time of the visit there was one (1) staff, and five (5) residents present. LPAs toured the facility inside and out and went over COVID-19 best practices for infection control and prevention with Alexander Angulo. The facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolating/quarantining residents and properly caring for residents with COVID-19 positive results and/or exposures. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the proper use and disposal of PPE. The entrance of the facility has a check in process for visitors that includes a temperature check and a symptom check. The residents have hand sanitizer available to them throughout the facility, and the bathrooms were stocked with hand soap and paper towels. The facility has postings throughout the facility for proper cough etiquette, proper hand washing procedure, and/or social distancing guidelines. LPAs requested to inspect the facility's Personal Protective Equipment (PPE) supply, which was located in the hallway cabinet. The facility has a full thirty (30) day supply of PPE items such as gloves, face shields, gowns, disinfectant, surgical masks, N95 masks, and hand sanitizer. All residents and staff are practicing all other COVID-19 precautions, which minimize the risk of them contracting COVID-19.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022

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 10/13/2022 12:30 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: HERITAGE RESIDENTIAL CARE	FACILITY NUMBER: 336407790
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(5)

87465.Incidental Medical and Dental Care. (h)The following requirements shall apply to medications which are centrally stored:(5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above by storing and labeling resident's medications in a plastic containers that are not the original prescription bottle from the pharmacy which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/14/2022
	Plan of Correction
1 2 3 4	The licensee has agreed to read regulation 87465 entirely and send LPA self certify letter that the regulation was read and understood. The licensee has agreed to train all staff on medication safety and storage. The licensee has agreed to send LPA documentation that a medication safety class has been scheduled. The licensee has agreed to send LPA documentation that each staff member has attended the medication training, this includes staff dates and signatures as evidence of attendance.

Type A

Section Cited

CCR

87303(e)(6)

87303. Maintenance and Operation. (e)Water supplies and plumbing fixtures shall be maintained as follows:(6)Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by not having a toilet tank cover on back of the toilet. The licensee covered the toilet with a wet piece of dirty cardboard and a pink and white incontinence disposable pad which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/14/2022
	Plan of Correction
1 2 3 4	The licensee has agreed to read regulation 87303 entirely and send LPA self certify letter that the regulation was read and understood. The licensee has agreed to purchase a new toilet tank cover. The licensee has agreed to remove and dispose the wet and dirty substance covered cardboard and pink and white incontinence disposable pad from the back of the toilet. The licensee has agreed to send LPA receipt of the purchase of the new toilet tank cover as well as picture proof that the new toilet tank cover was installed on the toilet.

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: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/13/2022 12:30 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: HERITAGE RESIDENTIAL CARE	FACILITY NUMBER: 336407790
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

87303. Maintenance and Operation. (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by not having cleaned window seals in the living room and kitchen area. There is a buildup of dirt and debris as well as a black colored substance which poses a potential health, safety, or personal rights risk to persons in care.
	POC Due Date: 10/20/2022
	Plan of Correction
1 2 3 4	The licensee has agreed to read regulation 87303 entirely and send LPA self certify letter that the regulation was read and understood. The licensee has agreed to contact a hazard company to inspect the dirt and debris to confirm whether or not it is safe to remove by the licensee or if the company needs to professionally remove the substance. The licensee has agreed to send LPA a receipt invoice of the hazard company’s evaluation of the window seals. As well as picture proof that the dirt debris substance has been cleaned and or removed.

Type B

Section Cited

CCR

87303(a)

87303. Maintenance and Operation. (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having a hole in kitchen wall. The hole is located above the cabinets near the refrigerator. The hole has insulation coming out of it which poses a potential health, safety, or personal rights risk to persons in care.
	POC Due Date: 11/01/2022
	Plan of Correction
1 2 3 4	The licensee has agreed to read regulation 87303 entirely and send LPA self certify letter that the regulation was read and understood. The licensee has agreed to contact a construction company to evaluate the hole in the wall. The licensee has agreed to send LPA a receipt invoice of the construction company’s evaluation of the hole. As well as picture proof that the hole has been repaired.

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: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/13/2022 12:30 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: HERITAGE RESIDENTIAL CARE	FACILITY NUMBER: 336407790
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

87303. Maintenance and Operation. (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having flooring in bedroom #2 near the sliding door that is peeling up from the surface. The flooring is lifting, has cracks, and has dirt and or debris coming out of it with a dark colored appearance which poses a potential health, safety, or personal rights risk to persons in care.
	POC Due Date: 11/01/2022
	Plan of Correction
1 2 3 4	The licensee has agreed to read regulation 87303 entirely and send LPA self certify letter that the regulation was read and understood. The licensee has agreed to contact a construction company to evaluate the flooring. The licensee has agreed to send LPA a receipt invoice of the construction company’s evaluation of the flooring. As well as picture proof that the flooring has been repaired.

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: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022

LIC809 (FAS) - (06/04)

Page: 4 of 5

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: HERITAGE RESIDENTIAL CARE	FACILITY NUMBER: 336407790
	VISIT DATE: 10/13/2022

NARRATIVE

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During today’s visit, LPAs found that the resident’s medications were removed from their prescription bottles and stored in plastic containers which poses an immediate health, safety, or personal rights risk to persons in care. LPAs took pictures of the resident's medications in the plastic containers.

LPAs found that the bathroom near the hallway closet had a toilet without a toilet tank cover. The facility is using a piece of wet and dirty cardboard covered by a pink and white incontinence disposable pad to cover the back of the toilet which poses a potential health, safety, or personal rights risk to persons in care. LPAs took pictures of the back of toilet and the cover that was placed on the back of toilet.

LPAs found the window seals in the living room and kitchen area had a buildup of dirt and debris as well as a black colored substance which poses a potential health, safety, or personal rights risk to persons in care. LPAs took pictures of the window seals.

LPAs found that in bedroom #2 the flooring near the sliding door was peeling up from the surface. The flooring is lifting, has cracks, and has dirt and or debris coming out of it with a dark colored appearance which poses a potential health, safety, or personal rights risk to persons in care. LPAs took pictures of the flooring.

LPAs found a hole in kitchen wall. The hole is located above the cabinets near the refrigerator. The hole has insulation coming out of it which poses a potential health, safety, or personal rights risk to persons in care. LPAs took pictures of the hole in wall.

Based on the observations made during today’s visit, five (5) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809), three (3) LIC809D forms, and appeal rights were discussed and provided to Caregiver Alexander Angulo.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022

LIC809 (FAS) - (06/04)

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