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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336423909
Report Date: 02/29/2024
Date Signed: 02/29/2024 03:44:11 PM


Document Has Been Signed on 02/29/2024 03:44 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:CAMPBELL'S LOVING HOME CARE INC.FACILITY NUMBER:
336423909
ADMINISTRATOR:CHARLES CAMPBELLFACILITY TYPE:
740
ADDRESS:18 NAPOLEON RD.TELEPHONE:
(760) 832-7791
CITY:RANCHO MIRAGESTATE: CAZIP CODE:
92270
CAPACITY:6CENSUS: 4DATE:
02/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Lalaine Campbell - CaregiverTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of conducting the annual inspection. LPA Colvin met with caregiver Lalaine Campbell and informed her of the purpose of today's inspection. Below is a summary of what was observed:

Infection Control: LPA Colvin observed that the facility has an updated Infection Control Plan on file and is demonstrating best practices in the facility to maintain a healthy environment for staff and residents. Such measures include: soap and disposable (one-time use) towels at hand washing stations, and tight-fitting lids on trash cans.

Staffing & Staff Records: LPA Colvin confirmed that there are sufficient staff present to meet the needs of residents. LPA Colvin observed that S1 has been working at the facility for two years and does not have criminal record clearance associated to the facility. In S1's file, LPA Colvin observed a written request from the Administrator to the Licensing office, dated 2/7/24, requesting to associate S1 to the facility. This request did not include the required information to process the transfer. LPA Colvin additionally observed a criminal background clearance transfer request in S1's file which was also incomplete, as it was missing S1's background clearance number. Deficiency cited. When a facility has staff present who do not have a criminal background clearance transferred to the facility, a civil penalty of $100 a day for every day the person is at the facility is assessed. LPA Colvin will be assessing a $500 civil penalty ($100 a day for 5 days), which is the maximum that can be assessed unless the violation is repeated.

Incidental Medical Services: LPA Colvin observed that resident medication is locked in the hallway and inaccessible to residents.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 02/29/2024 03:44 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: CAMPBELL'S LOVING HOME CARE INC.
FACILITY NUMBER: 336423909

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) 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: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in1 of 3 staff members (S1) which poses an immediate safety risk to persons in care. LPA Colvin observed that S1 is not associated to the facility and has been working at the location for 2 years.
POC Due Date: 03/01/2024
Plan of Correction
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Caregiver agrees to have S1 associated to the facility. LPA Colvin reccomends using Guardian for rapid results for associating S1. Caregiver to self-certify that S1 has succesfully been associated. Self-certification to be submitted to LPA Colvin by Plan of Correction date of 3/1/24.
Section Cited
Care of Bedridden Residents
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: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 02/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/29/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


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: CAMPBELL'S LOVING HOME CARE INC.
FACILITY NUMBER: 336423909
VISIT DATE: 02/29/2024
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Physical Plant: LPA Colvin toured the facility and observed that there a sufficient bedrooms and bathrooms for both staff and residents. LPA Colvin observed the required furniture and linen to be present and in good condition in resident bedrooms. LPA Colvin measured the hot water in the bathroom faucets to be 106.8 degrees. LPA Colvin tested the facility's carbon monoxide alarm and smoke detectors and found them to be operational. LPA Colvin observed that sharp objects like knives were locked in the kitchen away from residents' reach. LPA Colvin observed sufficient supply of perishable and non-perishable food and utensils and dishes for the residents in care.

Due to time constraints, the annual will be continued on a later date. Observations were documented and will be addressed during the annual continuation.

An exit interview was conducted with Caregiver Lalaine Campbell and a copy of this report, LIC809D, LIC421BG, and appeal rights were provided.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3