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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336410303
Report Date: 09/22/2023
Date Signed: 09/22/2023 04:58:21 PM

Document Has Been Signed on 09/22/2023 04:58 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:SIMCARE HOMES LLCFACILITY NUMBER:
336410303
ADMINISTRATOR:PERLITA SIMANFACILITY TYPE:
740
ADDRESS:155 BRACEBRIDGE ROADTELEPHONE:
(951) 429-7142
CITY:RIVERSIDESTATE: CAZIP CODE:
92506
CAPACITY: 6CENSUS: 4DATE:
09/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Licensees Wilfredo SimanTIME COMPLETED:
05:15 PM
NARRATIVE
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On 9/22/2023, Licensing Program Analyst (LPA) Janette Romero arrived unannounced at the facility to conduct an annual required visit. LPA was greeted and granted entry by Staff #1 (S1) who was informed of the purpose of visit. During the visit, there was two (2) staff and four (4) residents present.

S1 and Staff #2 (S2) present during today's inspection did not have a criminal record clearance on file. S1 has reportedly been working in the facility for 4 months, and has been working 5 days a week. S2 has reportedly been working in the facility for 2 months, and has been working 5 days a week as well. Civil penalties were assessed.

LPA called Licensee Perlita Siman and requested for Licensee to come to the facility. Licensees Wilfredo and Perlita Siman arrived at the facility and met with LPA. Licensees informed LPA that they sold the facility on 5/1/2023, but did not notify the Department until 5/5/2023. Deficiency cited.

The facility is approved to care for six (6) non-ambulatory elderly residents, and has a hospice waiver for two (2). LPA toured the facility's interior and exterior. During the visit, LPA observed the following:

Kitchen: LPA observed kitchen area to be clean. Food is stored in a safe and healthful manner. The facility had a 2-day supply of perishable food items and 7-day of non-perishable food items. Knives were secured in a locked kitchen drawer. Fire extinguisher is charged and mounted near the kitchen. Resident medications were secured in a kitchen cabinet.

Continued on LIC809-C.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2023
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 6
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: SIMCARE HOMES LLC
FACILITY NUMBER: 336410303
VISIT DATE: 09/22/2023
NARRATIVE
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Continued from LIC809.

Hallway: LPA toured the hallway and observed hallway to be clean with no pathway obstruction. Carbon monoxide and smoke detectors were tested and functioning properly.

Bedrooms: Resident bedrooms were each furnished with a bed, chair, closet, clothing storage and lighting.



Bathrooms: The facility has clean towels, blankets, and linen, available in different colors for the residents in care. Bathrooms have a working toilet, wash basin, and were equipped with a grab bar and nonskid mats in the shower. The hot water temperature in two (2) resident bathrooms measured at 139- and 155-degrees Fahrenheit. Deficiency cited.

Yard/Outside Area: Covered patio seating is available for residents. A brick wall secured the entire backyard. All outdoor pathways were free of obstructions. No bodies of water were observed.

Centrally Stored Medications: Resident medications for all four (4) residents were transferred out of their original containers and pre-poured onto small clear cups only labeled with the residents' names and AM/PM/B4BF/BT. Deficiency cited.

Resident Records: A record review revealed the following:

Prior to Resident #1's (R1's) acceptance at the facility, R1 did not have a medical assessment, signed by a physician, made within the last year. Resident #2's last medical assessment was conducted on 6/13/2022. Resident #3's last medical assessment was conducted on 1/14/2021. The facility did not obtain updated medical assessments for R2 and R3 to determine their care needs. Deficiencies cited.

During today's visit, LPA observed six (6) deficiencies faulting the facility. An exit interview was conducted, and a copy of this report was reviewed and provided to Licensee Wilfredo Siman along with LIC809-Ds, LIC421BG, and Appeal Rights.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023
LIC809 (FAS) - (06/04)
Page: 1 of 1
Document Has Been Signed on 09/22/2023 04:58 PM - It Cannot Be Edited


Created By: Janette Romero On 09/22/2023 at 03:18 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: SIMCARE HOMES LLC
FACILITY NUMBER: 336410303

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.191(a)(1)
(a) Notwithstanding Section 1569.19, in the event of a sale of a licensed facility where the sale will result in a new license being issued, the sale and transfer of property and business shall be subject to both of the following: (1) The licensee shall provide written notice to the department and to each resident or his or her legal representative of the licensee's intent to sell the facility at least 30 days prior to the transfer of the property or business, or at the time that a bona fide offer is made, whichever period is longer.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in by failing to notify the licensing agency thirty (30) days prior to the transfer of the property or business, which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/02/2023
Plan of Correction
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Licensee agreed to provide a statement of understanding regarding Health and Safety Code section 1569.19(a)(1) Sale of licensed facility; resulting issuance of new license; procedure. Proof of correction to be submitted to LPA by COB on POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Janette Romero
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2023


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 09/22/2023 04:58 PM - It Cannot Be Edited


Created By: Janette Romero On 09/22/2023 at 04:06 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: SIMCARE HOMES LLC
FACILITY NUMBER: 336410303

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above due to LPA discovering that Staff #1 and Staff #2 present during LPA's inspection did not have a criminal background clearance. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/23/2023
Plan of Correction
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Licensee agrees to immediately remove S1 and S2 from the facility, and obtain a background clearance prior to S1 and S2 working in the facility. Licensee to provide proof of submission of background clearance to LPA by POC date. LPA observed S1 and S2 leaving property.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Janette Romero
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2023


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 09/22/2023 04:58 PM - It Cannot Be Edited


Created By: Janette Romero On 09/22/2023 at 04:06 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: SIMCARE HOMES LLC
FACILITY NUMBER: 336410303

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(3)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above due to LPA measuring the hot water temperature in both resident bathrooms, which measured 139- and 155-degrees F., which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/02/2023
Plan of Correction
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Licensee agreed to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). Proof of correction to be submitted to LPA by COB on POC due date.
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above due to LPA finding that R1 did not have a medical assessment, signed by a physician, made within the last year, prior to acceptance at the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/02/2023
Plan of Correction
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Licensee agreed to submit a statement of understanding regarding obtaining medical assessments, signed by a physician, within the last year, prior to accepting residents at the facility. Proof of correction to be submitted to LPA by COB on POC due date.
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:Janette Romero
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2023


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 09/22/2023 04:58 PM - It Cannot Be Edited


Created By: Janette Romero On 09/22/2023 at 04:06 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: SIMCARE HOMES LLC
FACILITY NUMBER: 336410303

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation and interview, the licensee did not comply with the section cited above due to LPA finding that resident medications for all 4 residents were transferred out of their original containers and prepoured onto small clear cups labeled with only resident's names and AM/PM/B4BF/BT, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/02/2023
Plan of Correction
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Licensee agreed to provide staff training regarding medication management and provide proof of correction to LPA by COB on POC due date.
Type B
Section Cited
CCR
87507(c)
(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident’s representative, if any, and the licensee or the licensee’s designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above due to LPA finding that R3 or their responsible party did not sign the admission agreement, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/02/2023
Plan of Correction
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Licensee agreed to obtain R3 or their representative's signature on R3's admission agreement. Proof of correction to be submitted to LPA by COB on POC due date.
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:Janette Romero
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2023


LIC809 (FAS) - (06/04)
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