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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336413183
Report Date: 10/18/2024
Date Signed: 10/18/2024 11:10:08 AM

Document Has Been Signed on 10/18/2024 11:10 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ROXIE'S CARE FACILITYFACILITY NUMBER:
336413183
ADMINISTRATOR/
DIRECTOR:		YVONNE HOLCOMBEFACILITY TYPE:
735
ADDRESS:25704 MARGARET AVENUETELEPHONE:
(951) 242-2841
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92551
CAPACITY: 6CENSUS: 3DATE:
10/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Yvonne HolcombeTIME VISIT/
INSPECTION COMPLETED:
11:20 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Abdoulaye Zerbo and Sara Martinez conducted an unannounced visit to the facility for the purpose of conducting a required annual inspection. The LPAs were greeted by licensee Yvonne Holcombe, notified of the purpose for the visit and were allowed to enter the facility to conduct the inspection.
Facility Overview: The facility is a single story building with 3 residents bedrooms, 1 staff bedroom and 2 bathrooms. There is no gated pool and there are no firearms on the premises.

Infection Control: LPAs observed that hygiene and cleaning supplies were available for regular facility maintenance. The facility’s infection control plan was reviewed and found to meet department requirements.

Physical Plant: The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. Laundry equipment was in good working condition. Sharp and dangerous objects were securely locked in kitchen cabinet next to the sink and inaccessible to residents. The smoke detector and carbon monoxide detector were working r and operational. LPAs observed fire extinguishers to be in compliance with the department requirements and with and expiration date of 09/11/2025. LPAs observed the hot water temperature to meet requirements at 108.8°F.

Food Service: The facility’s kitchen was clean and equipped to prepare food. The facility maintained the required two-day supply of perishable foods and a seven-day supply of non-perishable foods.


Continued on LIC809-C.....
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE: DATE: 10/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2024
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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ROXIE'S CARE FACILITY
FACILITY NUMBER: 336413183
VISIT DATE: 10/18/2024
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Care & Supervision/Administration: Adequate staff were present to supervise clients during the visit. The administrator holds a current administrator’s certificate with expiration date of June 18th, 2025 and a CPR certification with the expiration date of 10-6-26

Record Review and Resident/Staff Files: LPAs reviewed files for two(2) staff members, confirming criminal clearances, updated training, and CPR/First Aid certification. Three residents' files were reviewed, Record reviewed reviled client 1 (C1) did not the physician report LIC 602 on file. Citation will be issued. LPA's observed Staff, resident files, were stored in closet in the staff room and emergency food, PPE's and water stored in the garage and the first aid kit was stored in a cabinet next to the dinning area.


Health-Related Services/Incidental Medical Services: All residents' medications were securely locked and located in the dinning area. LPAs observed client 2 (C2) medication was stored in a separate container different from the original packaging. Citation will be issued.

Disaster Preparedness: LPAs reviewed the facility’s emergency and disaster plan, including documentation of the last fire drill conducted on 9-1-2024, which met department requirements. All facility exits were clear of obstructions.

An exit interview was conducted and a copy of the report was provided to license Yvonne Holcombe and the appeal rights was provided.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/18/2024 11:10 AM - It Cannot Be Edited


Created By: Abdoulaye Zerbo On 10/18/2024 at 10:47 AM
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: ROXIE'S CARE FACILITY
FACILITY NUMBER: 336413183

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(k)

80075 Health Related Services
(k) The following requirements shall apply to medications which are centrally stored: b (5) Each client's medication shall be stored in its originally received container.

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 in 1 out of 3 client medication were not in their original container which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/01/2024
Plan of Correction
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Licensee will conduct staff training on the regulation cited above and will provide proof of training to LPA by the POC date 11/01/2024
Type B
Section Cited
CCR
80069(a)(1)

80069 Client Medical Assessment
(a) Except for licensees of ARFs , prior to or within 30 calendar days following the acceptance of a client, the licensee shall obtain a written medical assessment of the client, as specified in Section 80069(c), which enables the licensee to determine his/her ability to provide necessary health related services to the client. The assessment shall be used in developing the Needs and Services Plan.

(1) The assessment shall be performed by a licensed physician or designee, who is also a licensed professional, and the assessment shall not be more than one year old when obtained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review the licensee did not comply with the section cited above in 1 out of 3 Physician Reports LIC 602 available for records review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/01/2024
Plan of Correction
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Licensee will send a copy of the completed physician report to LPA by the POC due date 11-1-24
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:Rikesha Stamps
LICENSING EVALUATOR NAME:Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2024


LIC809 (FAS) - (06/04)
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