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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336413282
Report Date: 11/09/2023
Date Signed: 11/09/2023 12:56:36 PM


Document Has Been Signed on 11/09/2023 12:56 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:TEMPLE COURT SENIOR CAREFACILITY NUMBER:
336413282
ADMINISTRATOR:ESTA HOBBSFACILITY TYPE:
740
ADDRESS:40009 TEMPLE CT.TELEPHONE:
(951) 461-4750
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY:6CENSUS: 0DATE:
11/09/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Licensee, Esta HobbsTIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced visit to the facility for an unrelated matter. This report will document deficiencies found by the department. LPA met with Licensee, Esta Hobbs who was informed of the purpose of the visit.

It was found through interviews and records review that Resident #1 (R1) had sustained three (3) falls at the facility on 9/11/22 and 9/12/22 that were not reported to R1's responsible party. It was also found that caregiver notes documented a fall occurring on 7/17/22 which was also not reported to the department per file review of incident reports sent by the facility. Therefore, it was found that the licensee failed to meet the reporting requirements. Deficiency is being cited under the California Code of Regulations Title 22. A plan of correction was created with the licensee.

An exit interview was conducted where this report, deficiency page, and appeal rights were reviewed and provided to Licensee, Esta Hobbs.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2023
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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Document Has Been Signed on 11/09/2023 12:56 PM - 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: TEMPLE COURT SENIOR CARE
FACILITY NUMBER: 336413282

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/10/2023
Section Cited
CCR
87211(a)(1)

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(a)...licensee shall furnish to...licensing...reports as the Department may require, including, but not limited to...(1) A written report shall be submitted...to the person responsible for the resident within seven days of the occurrence of any of the events specified...
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The licensee agreed to allow responsible parties to view records for residents and submit this writting to the LPA by POC due date.
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This requirment was not met as evidenced by: Based on records review ad interview the licensee failed to report incident to R1's responsible party and licensing. This posed a potential health, safety or personal rights risk.
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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: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2023
LIC809 (FAS) - (06/04)
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