336423324-1-19-2024-18-AS-JARA-CZN3QM-20240119172724

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336423324
Report Date: 01/19/2024
Date Signed: 01/19/2024 05:27:30 PM

Document Has Been Signed on 01/19/2024 05:27 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:	PARTNERS N CARE SENIOR RESIDENCE		FACILITY NUMBER:	336423324
ADMINISTRATOR:	BEVERLEE VAUGHAN		FACILITY TYPE:	740
ADDRESS:	5873 BUD COURT		TELEPHONE:	(951) 213-6314
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92506
CAPACITY:	6	CENSUS: 6	DATE:	01/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Staff, Karen Vaughan		TIME COMPLETED:	05:30 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	Licensing Program Analyst (LPA) Janira Arreola conducted a required annual visit. LPA was greeted and was granted entry and met with Staff, Karen Vaughan, who was informed of the purpose of the visit. At time of visit there were (6) clients and (3) staff present. The facility is a two story home with the downstairs housing residents, with (4) bedrooms and (3) bathrooms with attached garage. The facility does a pool which has a locked gate surrounding it. No fire arms are kept at the facility. The facility is designated a residential home for the elderly serving elderly ages 60 and above. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following: Infection Control: LPA observed the hand washing stations in the facility. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. The facility has an infection control plan. Physical Plant: Physical plant, floors, windows, and doors were observed to be clean and fixtures and furniture were present and in good repair. The facility's outdoor area was observed to be free of hazards. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to clients. The carbon monoxide detector was operation during the time of the visit. The LPA observed video surveillance in the entry way of the facility. The facility does not have signed consent forms or waiver for video surveillance on file with the department. The deficiency was cited and plan of correction was created with staff. Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024

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: PARTNERS N CARE SENIOR RESIDENCE	FACILITY NUMBER: 336423324
	VISIT DATE: 01/19/2024

NARRATIVE

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Record Review and Resident/Staff Files: LPA reviewed staff files and training that contained staff criminal clearance and updated training along with CPR/First Aid. Client files were reviewed and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: All client medication was locked in laundry room. LPA reviewed client medications and found M1 was not initialed from 1/13 to 1/18, and there was a physician's report and discrepancy on the MARS log for M2 on medication dosage. The deficiency was cited and plan of correction was created with staff.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing last fire drill conducted October 2023. The staff stated they would conduct a drill by the end of the month. LPA observed all facility exits were clear from obstructions.

An exit interview was conducted where a copy of this report along with deficiency page and appeal rights were provided to Staff, Karen Vaughan.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 01/19/2024 05:27 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: PARTNERS N CARE SENIOR RESIDENCE	FACILITY NUMBER: 336423324
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87468.1

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above with (1) video survillence device begin used in the facility entry way which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/26/2024
	Plan of Correction
1 2 3 4	The licensee agreed to send the LPA waiver for the video survillence in the common area, and addendum to the admission agreement for the resident to sign consent form.

Type B

Section Cited

CCR

87465(a)(1)

87465 Incidental Medical and Dental Care (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: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above with M1 which did not have a specified dosage time on doctor's order and inaccurate information reflected on MARS sheet. LPA also found medication that was not initaled on MARS which had was allegedly refused by resident according to staff but not indicated refusal. This posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/19/2024
	Plan of Correction
1 2 3 4	The licensee agreed to have the MARS updated and physican's order for medication accurately reflecting the time that it should be adminitered.

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	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024

LIC809 (FAS) - (06/04)

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