336408203-8-12-2024-18-AS-SJEN-D83TM8-20240812145044

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336408203
Report Date: 08/12/2024
Date Signed: 08/12/2024 02:50:51 PM

Document Has Been Signed on 08/12/2024 02:50 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	TENDER LOVING CARE ASSISTED LIVING		FACILITY NUMBER:	336408203
ADMINISTRATOR:	MARIA KRAWCZYK		FACILITY TYPE:	740
ADDRESS:	30595 AVENIDA DEL PADRE		TELEPHONE:	(760) 324-0466
CITY:	CATHEDRAL CITY	STATE: CA	ZIP CODE:	92234
CAPACITY:	6	CENSUS: 3	DATE:	08/12/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:41 PM
MET WITH:	Maria Krawczyk, administrator		TIME COMPLETED:	03:05 PM

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Licensing Program Analyst (LPA), Seo Jeon, made an unannounced visit to the facility for the purpose of conducting a required annual inspection. The LPA was allowed to enter the facility to conduct the inspection. On today’s visit the LPA met with Administrator, Maria Krawczyk and she was notified of the purpose for the visit.

The facility is a single story home with 4 bedrooms and 2 bathrooms, complete with an attached garage. There are no pools or other bodies of water on the premises. The clients served are adults 60 and up.

The LPA observed the hand washing stations in the facility restrooms. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan and found all required infection control measures.

A tour of the interior and exterior areas of the facility was conducted. Per the administrator, no known weapons are stored in the home. The facility is being maintained at a comfortable temperature. All outdoor and indoor passageways are kept free of obstruction. There are grab bars for each toilet and shower used by residents. Hot water temperature was measured at 105 degrees F. The facility's carbon monoxide and smoke detectors were tested by the Administrator and were observed to be in operating condition.

Kitchen area is clean and organized. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. Chemicals and sharps are locked in the kitchen cabin.

Continues on LIC809-C...

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Seo Jeon	TELEPHONE: 951-248-0309
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2024

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: TENDER LOVING CARE ASSISTED LIVING	FACILITY NUMBER: 336408203
	VISIT DATE: 08/12/2024

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Adequate staff are present for the supervision of clients. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The listed administrator possesses an administrator certificate with expiration date of 2-26-2025.

LPA reviewed two (2) staff files and training. All staff have criminal clearance and updated training along with CPR/First Aid Certification. Three (3) client files were reviewed and possessed all required paperwork.

All client medication was locked in a cabinet located in the kitchen area. LPA reviewed medications for three (3) clients and found all medication listed on MARs and all required labeling was found to be in place.

LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing the facility performs quarterly fire and earthquake drills, which met the department requirements. LPA observed all facility exits were clear from obstructions. First aid kit is observed to be fully stocked with all required items.

No deficiencies were cited per Title 22, Division 6 of the California Code of Regulations at this time. LPA will be issuing a technical violation regarding, CCR 87465(h)(5)) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. The administrator stated that she will keep all medications in their original containers. The administrator immediately called the pharmacist and requested all medications to be in bubble packs in the future.

An exit interview was conducted where a copy of this report was provided to licensee/administrator, Maria Krawczyk.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Seo Jeon	TELEPHONE: 951-248-0309
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2024

LIC809 (FAS) - (06/04)

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