336408482-12-21-2023-18-AS-JARA-CYQRAP-20231221115127

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336408482
Report Date: 12/21/2023
Date Signed: 12/21/2023 11:52:14 AM

Document Has Been Signed on 12/21/2023 11:52 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:	CUNNINGHAM RES. CARE HOME III		FACILITY NUMBER:	336408482
ADMINISTRATOR:	ALICIA CUNNINGHAM		FACILITY TYPE:	740
ADDRESS:	24702 ORMISTADRIVE		TELEPHONE:	(951) 485-4697
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92553
CAPACITY:	6	CENSUS: 4	DATE:	12/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Licensee, Alicia Cunnigham		TIME COMPLETED:	12:00 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 Analyst (LPA) Janira Arreola conducted a required annual visit. LPA was greeted and was granted entry and met with Licensee, Alicia Cunnigham , who was informed of the purpose of the visit. At time of visit there were (1) resident and one (3) staff present. The facility is a one story home with (5) bedrooms and (2) bathrooms with attached garage. The facility does not have a pool or fire arms. The facility is designated as a residential care facility for the elderly and the residents served are elderly ages 60 and above. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following: Infection Control: LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. The facility has an infection control plan and documented training for staff on infection control. Physical Plant: Physical plant, floors, windows, and doors were observed, fixtures and furniture were present and in good repair. The facility's outdoor area was observed to be free of hazards and contained outdoor furniture and shaded area for clients. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to clients. The smoke detector and carbon monoxide was operational, and the hot water temperature 106.7F. During the time of the visit LPA observed insects on resident medication bin, and several flies and mosquitos in the facility living room. LPA also observed numerous bags of recyclable cans and bottles in garage and backyard. Deficiency was cited for facility staff to keep facility free of insects and free of excess debris as to not attract pests. Plan of correction was documented with licensee. LPA also observed the cleaning chemical in the resident restroom were secured with a wooden dowel and not a lock. Technical note was documented for staff to ensure cleaning chemicals are locked and inaccessible to residents.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

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: CUNNINGHAM RES. CARE HOME III	FACILITY NUMBER: 336408482
	VISIT DATE: 12/21/2023

NARRATIVE

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Food Service: LPA observed facility kitchen had the ability to prepare food and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.

Record Review and Resident/Staff Files: LPA reviewed staff files and training that contained staff criminal clearance and updated training along with CPR/First Aid. Client files were reviewed and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: All resident medication was locked in the kitchen cabinet. LPA reviewed resident medications for (2) residents and found all medication listed on MARS and all required labeling was found to be in place. LPA review MARS for all residents and found documentation was up to date and accounted for.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA documented technical note for licensee to update the plan to new LIC610D. LPA reviewed documentation showing last fire drill conducted 11/1/23. LPA observed all facility exits were clear from obstructions.

An exit interview was conducted where a copy of this report along with LIC809-D and appeal rights were provided to Licensee, Alicia Cunnigham.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/21/2023 11:52 AM - 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: CUNNINGHAM RES. CARE HOME III	FACILITY NUMBER: 336408482
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/21/2023

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 with numerous flies, mosquitos and insects observed in the facility living room, and numerous cans of recyclable cans and bottles in backyard and garage. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/04/2024
	Plan of Correction
1 2 3 4	The licensee agreed to have the cans and bottles removed by the POC due date and send LPA proof of removal. The licensee also agreed to have extermination services conducted inside the home and maintain insect light in living room and dinning area of the facility. The invoice for extermination service is due by the POC due date.

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: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

LIC809 (FAS) - (06/04)

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