Community Care Licensing

SUPERVISOR'S NAME: Joel Esquivel TELEPHONE: (951) 202-5067 LICENSING EVALUATOR NAME: Janira Arreola TELEPHONE: 951-248-2222 LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2022

Document Has Been Signed on 05/03/2022 05:10 PM - It Cannot Be Edited

FACILITY NAME: HILLS OF ALCOBA, THE	FACILITY NUMBER: 336410195
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/03/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/13/2022 Section Cited	1 2 3 4 5 6 7	(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed.
Type B 05/13/2022 Section Cited	1 2 3 4 5 6 7	Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years…”
Type B 05/13/2022 Section Cited	1 2 3 4 5 6 7	The following requirements shall apply to medications which are centrally stored: Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.
Type B 05/13/2022 Section Cited	1 2 3 4 5 6 7	) The following requirements shall apply to medications which are centrally stored: The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year ..”

SUPERVISOR'S NAME: Joel Esquivel TELEPHONE: (951) 202-5067 LICENSING EVALUATOR NAME: Janira Arreola TELEPHONE: 951-248-2222 LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2022

Document Has Been Signed on 05/03/2022 05:10 PM - It Cannot Be Edited

FACILITY NAME: HILLS OF ALCOBA, THE	FACILITY NUMBER: 336410195
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/03/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/13/2022 Section Cited	1 2 3 4 5 6 7	A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.
Type B 05/13/2022 Section Cited	1 2 3 4 5 6 7	Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
Type B 05/13/2022 Section Cited	1 2 3 4 5 6 7	All personnel records shall be maintained at the facility and shall be available to the licensing agency for review. Regarding LIC500
Type B 05/13/2022 Section Cited	1 2 3 4 5 6 7	The licensee shall ensure that a current register of all residents in the facility is maintained…

SUPERVISOR'S NAME: Joel Esquivel TELEPHONE: (951) 202-5067 LICENSING EVALUATOR NAME: Janira Arreola TELEPHONE: 951-248-2222 LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2022

Document Has Been Signed on 05/03/2022 05:10 PM - It Cannot Be Edited

FACILITY NAME: HILLS OF ALCOBA, THE	FACILITY NUMBER: 336410195
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/03/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/13/2022 Section Cited	1 2 3 4 5 6 7	The licensee shall notify the Department, in writing, within thirty (30) days of the hiring of a new administrator. The notification shall include the following:
Type B 05/13/2022 Section Cited	1 2 3 4 5 6 7	facility Should be clean and in good repair for the residents and staff. Facility had soiled oven, diswasher needed repair, Debris was noted on outside the facility.
Type B 05/13/2022 Section Cited	1 2 3 4 5 6 7	LPA observed that knives was left unlocked at the kitchen area, residdents were present and can be a potential danger to the residents and staff.
	1 2 3 4 5 6 7

SUPERVISOR'S NAME: Joel Esquivel TELEPHONE: (951) 202-5067 LICENSING EVALUATOR NAME: Janira Arreola TELEPHONE: 951-248-2222 LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2022