336423700-1-14-2025-18-AS-SMAZ-DCWVL3-20250114153115

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336423700
Report Date: 01/14/2025
Date Signed: 01/14/2025 03:31:21 PM

Document Has Been Signed on 01/14/2025 03:31 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 SAMARITAN		FACILITY NUMBER:	336423700
ADMINISTRATOR/ DIRECTOR:	SALOTE TUPOU		FACILITY TYPE:	740
ADDRESS:	3839 STRONG STREET		TELEPHONE:	(951) 742-5188
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92501
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	01/14/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:33 AM
MET WITH:	Salote Tupou, Licensee		TIME VISIT/ INSPECTION COMPLETED:	03:40 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), Stephanie Martinez, conducted a required annual inspection at the facility. The LPA was allowed entrance and met with Licensee Representative, Salote Tupou, and Administrator, Vaiasani Tupou. The LPA informed the Licensee and Administrator of the purpose for the visit. The inspection included the following: Food Service: The LPA inspected the facility's kitchen areas and food supply. The LPA observed all food to be of good quality. All readily perishable foods and beverages capable of supporting rapid and progressive growth of micro-organisms were stored in covered containers at appropriate temperatures. Soaps, detergents, cleaning compounds and similar substances were stored in areas separate from food supplies. All kitchen areas were kept clean and free of litter, rodents, vermin, and insects. Staff were observed to be meeting resident's modified diets. Physical Plant: The facility consists of three (3) resident bedrooms, one (1) meeting room/office, one (1) staff room, three (3) bathrooms, a kitchen and dinning area, a living room, a yard with sufficient seating and space for activities, and an Accessary Dwelling Unit (ADU). There are no bodies of water located on the property. According to Licensee Tupou, there are no weapons stored at the facility. The facility is being maintained at a comfortable temperature. All outdoor and indoor passageways were kept free of obstruction and are free of debris and other trash. There are grab bars for each toilet and shower used by residents. Resident showers have slip resistant mats present. Smoke detectors and carbon monoxide devices were tested and were observed to be in operating condition. The facility was kept exceptionally clean, organized and free of any odors. Record Review: All staff were observed to have appropriate fingerprint clearances; however, one uncleared adult was observed to be residing in the ADU on the property. According to Licensee Tupou, the individual was a renter and had not been fingerprint cleared. A citation and civil penalty will be issued. Staff

Rikesha Stamps	TELEPHONE: (951) -212-0616
Stephanie Martinez	TELEPHONE: (951) 204-5924
	DATE: 01/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025

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: 01/14/2025

NARRATIVE

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responsible for direct care and supervision have current First Aid and CPR training. Training on dementia care and medication administration has been completed. The licensee appears to be operating the facility within the conditions specified on the license. The facility currently has an approved Hospice Waiver for one (1) resident; and there are currently no residents in care receiving hospice services. There is an emergency disaster plan in place. Proof of emergency drills was observed on file. The licensee (TUPOU FAMILY, INC) is a current and active corporation. The LPA observed current liability insurance on file.

Medication Review: The LPA inspected resident medications. Medications were observed to be well organize and inaccessible to unauthorized individuals. Centrally stored medication destruction records were observed on file.

Licensee Tupou agreed to provide the LPA with a copy of the current liability insurance, staff schedule, a resident roster, and a plan on how the ADU will be utilized in the future, along with any supportive documents. Licensee Tupou confirmed she did decide to retract the capacity increase for non-ambulatory residents, which originally included the use of the ADU for the facility.

An exit interview was conducted with the Licensee and Administrator, in which this report was reviewed, and a copy was provided, along with appeal rights and other supportive records.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie Martinez	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/14/2025 03:31 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: 01/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Criminal Record Clearance: All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Obtain a California clearance or a criminal record exemption as required by the Department… 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 in 1 out of 1 uncleared adult residing at the facility. This poses an immediate health, safety and personal rights risk to persons in care.
	POC Due Date: 01/14/2025
	Plan of Correction
1 2 3 4	The uncleared adult left the facility prior to the conclusion of the LPA's visit.

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.

Rikesha Stamps	TELEPHONE: (951) -212-0616
Stephanie Martinez	TELEPHONE: (951) 204-5924
	DATE: 01/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025

LIC809 (FAS) - (06/04)

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