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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336408381
Report Date: 04/17/2024
Date Signed: 04/17/2024 02:52:01 PM


Document Has Been Signed on 04/17/2024 02:52 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:ST. MARY'S LOVE AND CARE HOMEFACILITY NUMBER:
336408381
ADMINISTRATOR:JANARD LANSANGANFACILITY TYPE:
740
ADDRESS:74039 KOKOPELLI CIRCLETELEPHONE:
(760) 779-9887
CITY:PALM DESERTSTATE: CAZIP CODE:
92260
CAPACITY:6CENSUS: 6DATE:
04/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Janard Lansangan - AdministratorTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of conducting the annual inspection. LPA Colvin met with Administrator Janard Lansangan and informed her of the purpose of today's inspection. Below is a summary of what was observed:

Infection Control: LPA Colvin observed that the facility has an updated Infection Control Plan on file and is demonstrating best practices in the facility to maintain a healthy environment for staff and residents. Such measures include soap and paper towels at hand washing stations, and hand washing guides posted above sinks.

Physical Plant: LPA Colvin toured the facility and observed that there a sufficient bedrooms and bathrooms for both staff and residents. LPA Colvin observed the required furniture and linen to be present and in good condition in resident bedrooms. LPA Colvin measured the hot water in the bathroom faucets to be 113.9 degrees. LPA Colvin tested the facility's carbon monoxide alarm and smoke detectors and found them to be operational. LPA Colvin toured the backyard and confirmed that no exits or pathways were blocked. LPA Colvin observed an in-ground pool in the backyard, which was gated and locked. LPA Colvin observed sufficient supply of perishable and non-perishable food and utensils and dishes for the residents in care. Knives and other sharp objects are kept locked away and out of resident reach.

Operational Requirements: LPA Colvin observed the facility to be operating within their licensed capacity of 6 non-ambulatory residents, one of which may be bedridden. Facility has a hospice waiver for 2 residents.

Incidental Medical Services: LPA Colvin observed that resident medication is locked in a cabinet and inaccessible to residents. LPA Colvin confirmed that the facility is not retaining any residents with prohibited health conditions.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2024
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


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: ST. MARY'S LOVE AND CARE HOME
FACILITY NUMBER: 336408381
VISIT DATE: 04/17/2024
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Staffing & Staff Records: LPA Colvin confirmed that there are sufficient staff present to meet the needs of residents. LPA Colvin additionally confirmed that the facility has an Administrator with a current Administrator Certificate. LPA Colvin reviewed staff records and confirmed current CPR/First Aid Certification as well as training relevant to the facility and residents' needs. All staff have criminal background clearance that has been transferred to the facility.

Resident Records: LPA Colvin reviewed the files for all 6 current residents to confirm that they have the required information present in their files, including Physician's Report, Admissions Agreement, and current Needs & Services Plan. LPA Colvin observed that three residents (R1, R2, & R3) diagnosed with Dementia have Physician's Reports that are over one year old. Deficiency cited.

Emergency Disaster Preparedness: LPA Colvin confirmed that the facility has an Emergency Disaster Plan on file. LPA Colvin observed that the facility has not documented an Emergency Disaster Drill since 2020. Deficiency cited.



Planned Activities: LPA Colvin confirmed with interviews of staff and residents that the facility provides activities for residents to engage in and are tailored to their interests.

An exit interview was conducted with Administrator Janard Lansangan and a copy of this report, LIC809D, LIC9098 Proof of Corrections, and appeal rights were provided.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 04/17/2024 02:52 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: ST. MARY'S LOVE AND CARE HOME
FACILITY NUMBER: 336408381

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 4 of 4 quarterly disaster drills, which poses a potential safety risk to persons in care. LPA Colvin observed that the facility has not conducted an Emergency Disaster Drill since 2020.
POC Due Date: 05/01/2024
Plan of Correction
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Administrator agrees to conduct an Emergency Disaster Drill by 5/1/24 and provide LPA Colvin with documentation of the drill. Administrator will also create a tentative schedule for the year for completing quarterly drills. Schedule will also be submitted to LPA Colvin by Plan of Correction date of 5/1/24.
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia: (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 of 6 residents (R1, R2, & R3) which poses a potential health risk to persons in care. LPA Colvin observed that three residents with Dementia have Physician's Reports older than one year (R1 - 2022, R2 - 2020, R3 - 2022).
POC Due Date: 05/01/2024
Plan of Correction
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Administrator agrees to obtain updated Physician's Reports for R1, R2, & R3. Administrator to provide LPA Colvin a copy of the reports by the Plan of Correction date of 5/1/24.
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: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3