336409400-8-26-2023-18-AS-JSRS-CV3U8P-20230826152152

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336409400
Report Date: 08/26/2023
Date Signed: 08/26/2023 03:22:03 PM

Document Has Been Signed on 08/26/2023 03:22 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	MESA VERDE HOME		FACILITY NUMBER:	336409400
ADMINISTRATOR:	MARYROSE KHAN		FACILITY TYPE:	735
ADDRESS:	29656 MESA VERDE CIRCLE		TELEPHONE:	(951) 309-3733
CITY:	MENIFEE	STATE: CA	ZIP CODE:	92584
CAPACITY: 6		CENSUS: 3	DATE:	08/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Maryrose Khan, Administrator		TIME COMPLETED:	03:25 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) Jacqueline Shaw Ross made an unannounced visit to the facility to complete the annual inspection. LPA arrived at the facility and was greeted by Administrator Maryrose Khan. LPA toured the inside and outside of the facility. The facility is approved to serve six (6) ambulatory developmental disabled adults, ages 18 through 59. At the time of the visit there three (3) clients present and one (1) staff present. The facility is a eight (8) bedroom three (3) bathroom two story home. Two (2) bedrooms are shared, two clients to each room and two (2) bedrooms are single rooms for the clients. There are also four (4) bedrooms reserved for staff and administrator. During the inspection, LPA observed the facility to be clean and in good repair with no pathway obstruction. The clients bedrooms, bathrooms and the facility's kitchen, as well as the common areas were inspected and found to be in compliance. All required postings were posted throughout the facility. The facility does not have firearms and/or ammunition on the grounds. The facility is completing emergency drills regularly. The last drill was conducted on 6/14/23. The facility is appropriately furnished. The water temperature was tested and measured at 105.4 degrees Fahrenheit. Indoor temperature measured at 73 degrees. The smoke alarms and carbon monoxide alarms were tested and found operable. LPA observed three fully charged fire extinguishers. The kitchen was observed to be fully stocked with a sufficient amount of food and supplies. Emergency food and water was stored in separate area in the garage. The knives were stored in a locked drawer in the kitchen. The medications are stored in a locked cabinet in the kitchen. P&I funds are kept in a locked room and are kept separate from facility funds. Chemicals and other hazardous items are kept in a locked cabinet in the garage. CONTINUE ON LIC809C

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2023

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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MESA VERDE HOME	FACILITY NUMBER: 336409400
	VISIT DATE: 08/26/2023

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
26
27
28
29
30
31
32

The backyard was observed to be fully fenced with plenty of shade and is free of hazards.

LPA reviewed facility files and records. Staff background clearances and trainings were observed to be current. Client files were observed to be current with required documents.

During a the kitchen refrigerator, LPA observed the following deficiency:

Client's insulin that was stored in the main refrigerator. LPA informed Administrator insulin should be kept in a locked refrigerator or locked box in the refrigerator. Administrator immediately removed the insulin from the refrigerator and placed in an area inaccessible to clients.

Based on observations made by LPA, the facility was cited and deficiency noted on LIC809D. An exit interview was conducted with Administrator Maryrose Khan and a copy of this report, LIC809D, and appeal rights was provided.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 08/26/2023 03:22 PM - It Cannot Be Edited

Created By: Jacqueline Shaw Ross On 08/26/2023 at 02:43 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: 08/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(2)

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) centrally stored medicines shall be kep in a safe locked area.... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, it was found that client's insulin was being kept in the facility fridge unlocked. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/08/2023
	Plan of Correction
1 2 3 4	Administrator stated they will keep medications in a locked refrigerator in the garage. Administrator shall conduct staff training on proper storage of clients medications. The training material and sign in sheet will be provided to the department as proof of POC.

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:

Jazmond D Harris

LICENSING EVALUATOR NAME:

Jacqueline Shaw Ross

LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3