336409400-9-28-2022-18-AS-CCON-CJPS3Z-20220928133157

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336409400
Report Date: 09/28/2022
Date Signed: 09/28/2022 01:32:26 PM

Document Has Been Signed on 09/28/2022 01:32 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
RIVERSIDE, CA 92507

FACILITY NAME:	MESA VERDE HOME		FACILITY NUMBER:	336409400
ADMINISTRATOR:	CHRISTINA ONG		FACILITY TYPE:	735
ADDRESS:	29656 MESA VERDE CIRCLE		TELEPHONE:	(951) 309-3733
CITY:	MENIFEE	STATE: CA	ZIP CODE:	92584
CAPACITY: 6		CENSUS: 6	DATE:	09/28/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Maryrose Kahn - Administrator		TIME COMPLETED:	01:45 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) Crystal Colvin arrived at the facility unannounced for the purpose of completing the facility's Annual Inspection. LPA Colvin met with Administrator Maryrose Kahn and advised of the purpose of the visit, and that the Annual Inspection will be focused on Infection Control. Below is a summary of what was observed: Infection Control: LPA Colvin went over COVID-19 best practices for infection control and prevention with Administrator Maryrose Kahn. LPA Colvin inquired as to if the facility has a COVID-19 Mitigation/Infection Control Plan, as Licensing does not have one on file. Administrator Maryrose Kahn stated that she believes that they have one, but did not have a copy of it on hand. LPA Colvin will be issuing a Technical Assistance (TA) Advisory Note today for the facility not having an Infection Control Plan on file or having submitted one to Licensing. Residents have hand sanitizer available to them, resident bathrooms were stocked with hand soap and paper towels. LPA Colvin observed the bathroom in resident room #3 to have paper towels and hand soap. While touring the facility, LPA Colvin did not observe any postings for cough etiquette, social distancing, or infection control. Additionally, there was no signs on the door regarding caution for COVID-19 symptoms or mandatory masks required. LPA Colvin will be issuing a TA Advisory Note for the lack of informational postings, as they are still recommended at this time. LPA Colvin requested to view the facility's PPE supplies (gloves, masks, and sanitizer, and isolation gowns), which was located in the facility garage and is an adequate supply of PPE. LPA Colvin went over the various recommended training for facility staff with Administrator Maryrose Kahn in relation to COVID-19 and confirmed that staff have been trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing PPE. LPA Colvin inquired as to if staff have been fit tested for N95 masks, and Administrator Maryrose Kahn informed LPA Colvin that at this time staff have not. LPA Colvin will be issuing a TA Advisory Note during today's inspection for staff not being fit tested for N95 masks.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2022

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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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
RIVERSIDE, CA 92507

FACILITY NAME: MESA VERDE HOME	FACILITY NUMBER: 336409400
	VISIT DATE: 09/28/2022

NARRATIVE

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LPA Colvin will not be issuing a deficiency for this item due to the facility not currently having any COVID-19 positive residents, and N95 masks only needing to be worn when a resident is COVID-19 positive or under observation while awaiting test results. LPA Colvin will be providing them with the information for Provider Information Notice (PIN) PIN-21-10-ASC which contains resources for getting staff fit tested for N95 masks.

Additionally, LPA Colvin observed staff present to not be wearing any type of face covering. At this time, face coverings are still required in all residential facilities. LPA Colvin will be issuing a TA Advisory Note for staff not wearing a face covering. LPA Colvin inquired about if the facility is screening their residents daily for COVID-19 symptoms, which includes checking their temperature. Administrator Maryrose Kahn stated that they are no longer screening their residents. LPA Colvin will be issuing a TA Advisory Note as it is still recommended for residents to be screened for symptoms daily, especially if they attend Day Program or go out in the community. LPA Colvin inquired as to if all staff are vaccinated, and Administrator confirmed that they are, so the facility is not required to COVID-19 test any staff regular. Administrator additionally confirmed that new staff obtain a negative COVID-19 test prior to starting employment at the facility, but did admit that the newest resident (R1) was not required to be COVID-19 tested prior to move in. LPA Colvin will be issuing a TA Advisory Note as it is still recommended for new residents to have a negative COVID-19 test prior to moving in to the facility to help prevent the spread of COVID-19.LPA Colvin observed a sign-in sheet at the front door of the facility, and confirmed that visitors and staff are being screened for symptoms prior to entering the facility.

Other: LPA Colvin observed one resident (R1) to be moving about the facility in an electric wheelchair. LPA Colvin confirmed R1 is non-ambulatory and dependent on the wheelchair through review of R1's physician's report. LPA Colvin inquired about this with the Administrator, as the facility is only licensed for ambulatory residents. Administrator stated that the Fire Marshall had provided them with non-ambulatory clearance in the past due to a prior resident needing it, but that she is aware that she needs to submit an Exception Request. LPA Colvin reviewed the paperwork from the Fire Marshall and confirmed that an inspection was done in 2018, wherein corrections were recommended for the facility if they wanted non-ambulatory residents. LPA Colvin observed that it looked like in 2019 the Fire Marshall confirmed the corrections were made (self-closing door), which LPA Colvin also confirmed was present during today's inspection. LPA Colvin notes, however, that the paperwork from the Fire Marshall is not a new approved fire clearance, but simply an inspection, which can be requested by the facility at their own expense.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2022

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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MESA VERDE HOME	FACILITY NUMBER: 336409400
	VISIT DATE: 09/28/2022

NARRATIVE

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In order for the facility to obtain a new Fire Clearance, which would permit the retention of non- ambulatory residents, and the facility's license would be updated to reflect the new clearance. However, this process has not been completed as evidenced by the facility's lack of Fire Clearance showing approval for non-ambulatory residents, and no follow-up inspection from Licensing to confirm the change. Therefore, the facility's retention of a non-ambulatory resident (R1) is in violation of their current Fire Clearance, and as a result, LPA Colvin is citing a deficiency and issuing a $500 immediate civil penalty. LPA Colvin additionally observed another resident (R2) leave the facility utilizing a walker, though the Administrator stated that R2's walker is temporary due to an injury, and R2 will be having the boot on their foot removed soon and should no longer need a walker.

Additionally, LPA Colvin confirmed that the Administrator on file for the facility with Licensing is no longer working for the facility as an Administrator, and Maryrose Kahn is the new Administrator (since May 2022). LPA Colvin informed Kahn that she will need to submit a Change of Administrator Packet to Licensing in order to have this information updated.

Based on observations made by LPA Colvin, the facility was cited and issued a civil penalty in the amount of $500. An exit interview was conducted with Administrator Maryrose Kahn and a copy of this report, LIC809 D, LIC 421IM, appeal rights, and LIC9102 TA Advisory Notes were provided.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/28/2022 01:32 PM - It Cannot Be Edited

Created By: Crystal Colvin On 09/28/2022 at 12:58 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: MESA VERDE HOME	FACILITY NUMBER: 336409400
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80020(b)(2)

Fire Clearance: (b) The applicant shall notify the licensing agency if the facility plans to admit any of the following categories of clients so that an appropriate fire clearance, approved by the city or county, fire department, the district providing fire protection services, or the State Fire Marshal, can be obtained prior to the acceptance of such clients: (2) Persons who are nonambulatory, as defined in Section 80001n.(1). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in 1 out of 6 residents, which poses an immediate health and safety risk to persons in care. LPA Colvin observed that R1 is non-ambulatory, but the facility does not have an approved Fire Clearance for non-ambulatory residents, and Licensing has not been notified of the intent to admit any non-ambulatory residents.
	POC Due Date: 09/29/2022
	Plan of Correction
1 2 3 4	Licensee agrees to submit an application requesting change of ambulatory status for the facility to request fire clearance for the non-ambulatory resident. Application due by Plan of Correction date of 9/29/22.

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:

Joel Esquivel

LICENSING EVALUATOR NAME:

Crystal Colvin

LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2022

LIC809 (FAS) - (06/04)

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