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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336423700
Report Date: 04/05/2024
Date Signed: 04/05/2024 01:15:06 PM


Document Has Been Signed on 04/05/2024 01:15 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:A GOOD SAMARITANFACILITY NUMBER:
336423700
ADMINISTRATOR:SALOTE TUPOUFACILITY TYPE:
740
ADDRESS:3839 STRONG STREETTELEPHONE:
(951) 742-5188
CITY:RIVERSIDESTATE: CAZIP CODE:
92501
CAPACITY:6CENSUS: 5DATE:
04/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Salote Tupou, LicenseeTIME COMPLETED:
01:20 PM
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Licensing Program Analyst (LPA), Stephanie Martinez, conducted a required annual inspection to the facility. The LPA was allowed entrance into the facility and met with Licensee, Salote Tupou, and Administrator, Vaiasini Tupou. The LPA informed the Licensee and Administrator of the purpose for the visit. The facility currently has an approved Hospice Waiver for one (1) residents. The inspection included the following:

Physical Plant: The facility consists of three (3) resident bedrooms, one staff room, a dinning area, a living space, an open kitchen, and an outdoor and patio space, with sufficient seating and space for activities. There are no bodies of water located on the property. According to Licensee Tupou, no weapons are stored in the home. The facility is being maintained at a comfortable temperature. All outdoor and indoor passageways are kept free of obstruction and are free of debris and other trash. There are grab bars for each toilet, bathtub and shower used by residents. Resident showers have non-skid mats present. The carbon monoxide and smoke detectors were tested by the Administrator and were observed to be in operating condition. The home was kept exceptionally clean and free of any odors.

Food Service: There is a minimum of 2 days of perishable foods and 1 week's supply of non-perishable foods. Sufficient supplies were observed to be available for resident use.

Record Review: All staff were observed to have appropriate fingerprint clearances. LPA did not observe any excluded individuals on the premises at time of visit. Staff responsible for direct care and supervision have current first aid and CPR training. Dementia care training was observed to be available and complete. The facility was not operating beyond the conditions specified on the license. The LPA was informed by Administrator Vaiasini that there are currently no resident in care who are receiving hospice services services. There is a disaster and mass casualty plan in place. Proof of emergency drills were observed on file. Facility records were kept well organized.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2024
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: A GOOD SAMARITAN
FACILITY NUMBER: 336423700
VISIT DATE: 04/05/2024
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Medication Review: The LPA reviewed medications for two residents. The LPA observed four medications found not to be labeled. The medications were being centrally stored for Resident Two (R2). All four medications were listed on R2's medication list. This violation poses a potential health, safety and personal rights risk to the resident in care. A citation will be issued.

An exit interview was conducted with Licensee Salote Tupou, in which this report was reviewed and a copy was provided, along with the LIC 811 and instructions on appeal rights.

SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 04/05/2024 01:15 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: A GOOD SAMARITAN
FACILITY NUMBER: 336423700

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(4)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in four out of four medications found not to be labeled. The medications were being centrally stored for Resident Two (R2). This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/12/2024
Plan of Correction
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Licensee stated proof of medication labels will be provided to the Department by the 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: Rikesha StampsTELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2024
LIC809 (FAS) - (06/04)
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