336424231-11-8-2023-18-AS-JARA-CXDQ2Y-20231108104755

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336424231
Report Date: 11/08/2023
Date Signed: 11/08/2023 10:48:42 AM

Document Has Been Signed on 11/08/2023 10:48 AM - 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:	ALOHA HOME CARE II, INC.		FACILITY NUMBER:	336424231
ADMINISTRATOR:	EDMONDANTE RAZON		FACILITY TYPE:	740
ADDRESS:	31318 NEUMA DR		TELEPHONE:	(760) 548-0032
CITY:	CATHEDRAL CITY	STATE: CA	ZIP CODE:	92234
CAPACITY:	6	CENSUS: 5	DATE:	11/08/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Staff, Elizabeth		TIME COMPLETED:	11:00 AM

NARRATIVE

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On 11/8/2023, Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit. LPA was granted entry and met with staff Elizabeth Razon, who was informed of the purpose of the visit. At the time of the visit there was (2) staff and (5) residents present.

The facility is a one story home with attached garage. No firearms or pools are present at the facility. The home has (6) bedrooms and (6) bathrooms. The clients served are 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: The LPA observed hand washing stations with hand hygiene supplies. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. The facility has a plan to train staff on infection control guidelines.

Physical Plant: Physical plant was observed to be clean and in good repair. The indoor and outdoor areas were 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 residents. The smoke detectors were operational, and the hot water temperature was recorded at 120F.

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: 11/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023

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: ALOHA HOME CARE II, INC.	FACILITY NUMBER: 336424231
	VISIT DATE: 11/08/2023

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Record Review and Resident/Staff Files: LPA reviewed staff files and training. Staff have criminal clearance and have updated training along with CPR/First Aid Certification. The administrator has proof of a processing administrator certificate with the department. Resident files were reviewed, and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: All client medication was locked. LPA reviewed resident medications, all of which were accounted for.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. The last fire drill was conducted 6/1/2023, the facility will be cited to conduct another fire drill. Plan of correction was created with administrator and staff. LPA observed emergency exits and emergency supplies.

An exit interview was conducted where a copy of this report, along deficiency page and appeal rights were reviewed and provided to staff, Elizabeth Razon.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 11/08/2023 10:48 AM - 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: ALOHA HOME CARE II, INC.	FACILITY NUMBER: 336424231
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(c)

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios...Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review and interview, the facility's last drill was performed five (5) months ago. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/29/2023
	Plan of Correction
1 2 3 4	The administrator and staff agreed to hold an emergency drill by the POC due date and send proof to the LPA.

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: 11/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023

LIC809 (FAS) - (06/04)

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