336423364-1-24-2024-18-AS-JARA-CZT3YM-20240124174009

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336423364
Report Date: 01/24/2024
Date Signed: 01/24/2024 05:40:19 PM

Document Has Been Signed on 01/24/2024 05:40 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:	ISLAND'S BEST HOME CARE LLC		FACILITY NUMBER:	336423364
ADMINISTRATOR:	ARCITA CAYABYAB		FACILITY TYPE:	740
ADDRESS:	30875 AVENIDA JUAREZ		TELEPHONE:	(760) 832-8975
CITY:	CATHEDRAL CITY	STATE: CA	ZIP CODE:	92234
CAPACITY:	6	CENSUS: 6	DATE:	01/24/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Administrator, Arcita Cayabyab		TIME COMPLETED:	05:45 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 Administrator, Arcita Cayabyab, 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 one story home with (5) bedrooms and (6) bathrooms with attached garage. The facility does not have a pool or fire arms. The facility serves elderly ages 60 and above. LPA conducted a tour of the interior and exterior and reviewed facility documents. Infection Control: LPA observed hand hygiene supplies, PPE equipment and cleaning supplies to do regular cleaning of the facility. The facility has a infection control plan on file. 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 carbon monoxide detector was operational during the visit. 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 food supply.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024

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: ISLAND'S BEST HOME CARE LLC	FACILITY NUMBER: 336423364
	VISIT DATE: 01/24/2024

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 it would found that (1) resident did not have an updated LIC602 per dementia regulations. Technical violation was issued.

Health Related Services/ Incidental Medical Services: All client medication was locked in closet. LPA reviewed client medications and found through observation and record review, medication for Resident #1 (R1) was being prepoured for the next morning. Deficiency was cited and plan of correction was created. Technical note was documented for staff to update plan of care for (1) resident.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing last fire drill conducted on November 2023. Technical note issued for staff to send documentation to LPA by 1/25/2024 close of business.

An exit interview was conducted where a copy of this report, appeal rights and deficiency page were provided to Administrator, Arcita Cayabyab.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024

LIC809 (FAS) - (06/04)

Page: 2 of 6

Document Has Been Signed on 01/24/2024 05:40 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: ISLAND'S BEST HOME CARE LLC	FACILITY NUMBER: 336423364
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(5)

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation,interview and record review, the licensee did not comply with the section cited above in with prepoured medication that was observed for (1) resident which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/31/2024
	Plan of Correction
1 2 3 4	The licensee agreed to retrain staff and send copy of inservice by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 01/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024

LIC809 (FAS) - (06/04)

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