<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336413282
Report Date: 01/17/2024
Date Signed: 01/17/2024 12:17:49 PM


Document Has Been Signed on 01/17/2024 12:17 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:
01/17/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Licensee, Esa HobbsTIME COMPLETED:
12:30 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
On January 17, 2024, Community Care Licensing (CCLD) held a meeting conducted in the Riverside Adult and Senior Care Regional Office. In attendance was Licensing Program Manager (LPM) Rikesha Stamps, Licensing Program Analysts (LPA)s, Janira Arreola and Crystal Colvin, and Licensee, Esta Hobbs.

The purpose of this report is to document the plan of correction that was agreed upon on 11/9/2023 for complaint control number 18-AS-20220926205159. During the office visit, it was confirmed with the licensee that the agreed upon plan of correction had not been submitted to the LPA by the POC due date. The time frame for POC inspection has lapsed, therefore the deficiencies will be re-cited on this report along with a new POC due date.

An exit interview was conducted with Licensee, Esta Hobbs where this report along with the LIC809D page, and appeal rights

SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2024
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 2


Document Has Been Signed on 01/17/2024 12:17 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: 01/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/18/2024
Section Cited
CCR
87468.2(a)

1
2
3
4
5
6
7
(a) In addition…residents…shall have all of the following personal rights:(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in...competency to meet their needs. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
The licensee agreed to conduct a re-training with staff on fall risk and supervision. Material used for training is to be sent to LPA by the POC due date
8
9
10
11
12
13
14
Based on interviews and records review it was found R1 had (3) unwitnessed falls on the same date. Where staff failed to supervise the resident, resulting in R1 sustaining a femoral fracture. This poses an immediate health, safety, or personal rights risk to residents in care.
8
9
10
11
12
13
14
Type A
01/18/2024
Section Cited
CCR87465(h)(5)

1
2
3
4
5
6
7
h)(5)Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.
1
2
3
4
5
6
7
The licensee will send LPA proof of material to be covered during staff in service to properly handel resident medications. This is due by the POC due date.
8
9
10
11
12
13
14
This requirment was not met as evidenced by: Based on interview and record review the licensee mismanged the medication by prepouring it for R1 for a full day in advance. This posed an immediate personal
8
9
10
11
12
13
14
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: 01/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2