336410270-3-29-2023-18-AS-YDEO-CQDLGC-20230329084432

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336410270
Report Date: 03/27/2023
Date Signed: 03/29/2023 08:44:59 AM

Document Has Been Signed on 03/29/2023 08:44 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	CHRISTMAS COTTAGE		FACILITY NUMBER:	336410270
ADMINISTRATOR:	ROSALYNNE VALIENTE		FACILITY TYPE:	740
ADDRESS:	330 S. SAN JACINTO ST		TELEPHONE:	(951) 765-1840
CITY:	HEMET	STATE: CA	ZIP CODE:	92543
CAPACITY:	14	CENSUS: 9	DATE:	03/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Kathline Hyland, Administrator		TIME COMPLETED:	03:35 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) Yolanda Delgado arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction, visit purpose and provided the facility with LPA identification and business card. Resident record review began. One (1) records were reviewed. LPA reviewed for admission agreement, medical assessment and TB test results, consent forms, identification and emergency information, appraisal needs and service plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. This facility is meeting documentation requirements. Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. The home is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured from 74.4 to 128.5 degrees F. Laundry facilities outdoors and storing laundry soap and other chemicals in secured closets. All outdoor and indoor passageways are free of obstruction. A locked area is provided for medications and sharp objects. LPA verified there is a telephone working at this location. Food Service- Food supply meets the requirement of one week supply of nonperishable and 2 day supply of perishables food on hand. A menu is posted, foods are dated to assure safety. Food prep areas are clean and organized. (Continued on next page)

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda Delgado	TELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023

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

FACILITY NAME: CHRISTMAS COTTAGE	FACILITY NUMBER: 336410270
	VISIT DATE: 03/27/2023

NARRATIVE

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(Continued from 809)

LPA began review of employee records. Two (2) records were reviewed. LPA reviewed employee record for first aid certification, fingerprint clearance, personnel/job application, health screening and TB test results, criminal record statement, employee rights, training verification, and current administrator certification. CPR and requirements have been met. The facility employs enough staff to maintain cleanliness and meet the needs of the clients in care. Administrator certification is present and current.

LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. The facility has not exceeded its capacity limitation and the structure remains unchanged according to the approved floor plan. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguishers are tested or replaced annually and were last done so on 01/06/2023. The facility is conducting emergency disaster drills. The last disaster drill was conducted on 1/10/2023.

LPA allocated time to prepare this report for delivery.

Based on the information received during this visit today, two (2) deficiencies and one (1) Technical Assistance advisory is being cited per Title 22, Division 6 of The California Code of Regulations.

This report was reviewed with and a copy provided to the facility representative. Appeal Rights were also provided at the time of the exit interview.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda Delgado	TELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/29/2023 08:44 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CHRISTMAS COTTAGE	FACILITY NUMBER: 336410270
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

(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 LPA Delgado observation, the licensee did not comply with the section cited above in there are two exterior window screens that are bent which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/06/2023
	Plan of Correction
1 2 3 4	Licensee will repair window screens and will email LPA pictures by 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: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda Delgado	TELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 03/29/2023 08:44 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CHRISTMAS COTTAGE	FACILITY NUMBER: 336410270
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA Delgado's observation and interview, the licensee did not comply with the section cited above in a dirty serrated knive with a brown handle was observed in the left side of the sink with other dishes in the kitchen which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/06/2023
	Plan of Correction
1 2 3 4	Administrator spoke to the one (1) staff on duty regarding leaving sharp objects iin sink. Administrator will conduct In-Service trainin with staff and email training record to LPA by 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: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda Delgado	TELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023

LIC809 (FAS) - (06/04)

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