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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336413304
Report Date: 10/03/2024
Date Signed: 10/03/2024 01:40:28 PM


Document Has Been Signed on 10/03/2024 01:40 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:EBEN HAVENFACILITY NUMBER:
336413304
ADMINISTRATOR:ELIZABETH ODUNJOFACILITY TYPE:
740
ADDRESS:30792 STONE CREEK CT.TELEPHONE:
(951) 679-7754
CITY:MENIFEESTATE: CAZIP CODE:
92584
CAPACITY:6CENSUS: 5DATE:
10/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Caregiver, Angelica AlamilloTIME COMPLETED:
01:50 PM
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On 10/3/2024, Licensing Program Analysts (LPAs) Janette Romero and Janira Arreola made an unannounced visit to the facility to conduct a required annual inspection. LPAs were greeted and granted entry by Caregiver, Angelica Alamillo who was informed of the purpose of the visit. The facility has a fire clearance for six (6) non-ambulatory elderly residents. The facility also has an approved hospice waiver for four (4) residents and LPA was informed two (2) residents are currently receiving hospice services at the facility. During the visit, there was two (2) staff and five (5) residents present. Facility representative, Adeola Ayodele arrived during the visit.

LPA toured the facility with Caregiver Alamillo, conducted interviews and reviewed records. During the tour, LPA observed indoor and outdoor pathways were free of obstructions. There were no bodies of water observed on the premises. Outdoor shaded seating is available for the residents in care. LPA toured the kitchen and observed the facility has a two-day supply of perishable foods and seven-day supply of non-perishable food items. Knives are secured in a locked kitchen cabinet next to the refrigerator. Cleaning solutions and disinfectants are secured in the locked garage. Caregiver Alamillo tested one (1) of the smoke alarms/carbon monoxide detectors and LPA observed it to be operational. LPA also observed charged fire extinguishers mounted throughout the facility, last serviced on 6/4/2024. Staff present have a criminal record clearance and are associated with the facility. Medications are secured in a locked hallway closet. LPAs reviewed the physical medications for Resident 1 (R1) and Resident 2 (R2) along with their Medication Administration Record for October 2024 and found facility staff documented administering a medication for R2 that is not listed in the latest medication list and was not found with their physical medications. Staff interviews conducted revealed facility staff are documenting administration of R1's routine medications for October 2024 on 10/3/2024 and not immediately after dispensing the medication from 10/1/2024 to 10/3/2024.

During today's visit, the facility was issued one (1) deficiency. An exit interview was conducted and a copy of this report was reviewed and provided to facility representative, Adeola Ayodele along with an LIC 809-D, Confidential Names List (LIC 811) and Appeal Rights.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: (951) 529-2930
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2024
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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Document Has Been Signed on 10/03/2024 01:40 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: EBEN HAVEN
FACILITY NUMBER: 336413304

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(4)
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. 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 due to Medication Administration Record discrepancies found during the review of R1 and R2s medications and resident records, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/11/2024
Plan of Correction
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Licensee stated they will conduct a staff training regarding proper medication management and documentation. Proof of correction to be submitted to LPA by close of business 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: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: (951) 529-2930
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2024
LIC809 (FAS) - (06/04)
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