336424363-4-4-2023-18-AS-JARA-CQKSAV-20230404134259

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336424363
Report Date: 04/04/2023
Date Signed: 04/04/2023 01:43:24 PM

Document Has Been Signed on 04/04/2023 01:43 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	CROWN MANOR		FACILITY NUMBER:	336424363
ADMINISTRATOR:	AGNES MARTINEZ		FACILITY TYPE:	740
ADDRESS:	28328 SEVILLA STREET		TELEPHONE:	(951) 672-6359
CITY:	MURRIETA	STATE: CA	ZIP CODE:	92563
CAPACITY: 6		CENSUS: 6	DATE:	04/04/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:47 AM
MET WITH:			TIME COMPLETED:	02:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit on 4/4/2023 at 09:47 a.m. LPA met with ... who was informed of the purpose of the visit. At the time of the visit there was (3) staff and (6) residents present.

The facility is a one story home with (5) bedrooms and (4) bathrooms home. The residents served are elderly ages 60 and above. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted (2)staff and (1)resident interview, and (1) resident interview was attempted. LPA observed the following:

Infection Control: The LPA observed the hand washing stations in the facility restrooms. LPA observed gloves and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan and found all required infection control measures. LPA observed PPE supplies at the facility. The LPA observed the training log for staff.

Physical Plant/Planned activities: LPA observed the resident bedrooms. Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. Laundry room was observed to be locked and was observed to be in good working condition. The dangerous objects were observed to be locked and inaccessible to clients.

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.

Care & Supervision/Administration: LPA observed t adequate staff are present for the supervision of clients. Emergency exiting plans, and personal rights were found posted in the facility. The listed administrator, possesses a current administrator's certificate.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023

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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CROWN MANOR	FACILITY NUMBER: 336424363
	VISIT DATE: 04/04/2023

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Record Review and Resident/Staff Files: LPA reviewed (2) staff files and training. All staff have criminal clearance and updated training along with CPR/First Aid Certification. Two (2) resident files were reviewed, and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: All client medications were locked in a medication cabinet. LPA reviewed client medications for (2) clients and found all medication listed on centrally stored lists and all required labeling was found to be in place. LPA reviewed the MARS sheet and found all medication was accounted for. LPA observed the facility has a first aid kit on the premises. LPA observed the facility had medications placed in containers that were not the original medication containers. LPA observed pill containers labeled "pm" in the medication cabinet. The facility will receive a deficiency for this, and LPA documented a plan of correction with the administrator during the visit.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing the facility last disaster drill on 2/1/2023, which met the department requirements. The Administrator stated they did not have the LIC610D at the facility due to them removing it to update it. LPA was able to review the emergency binder that contained all the required LIC610D information. LPA observed all facility exits were clear from obstructions. LPA observed emergency food supply in the facility garage as well as emergency water.

An exit interview was conducted where a copy of this report was provided to licensee, Agnes Martines, along with LIC809-D and appeal rights.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/04/2023 01:43 PM - It Cannot Be Edited

Created By: Janira Arreola On 04/04/2023 at 01:30 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CROWN MANOR	FACILITY NUMBER: 336424363
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(5)

Incidental Medical and Dental Care Services

(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) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/10/2023
	Plan of Correction
1 2 3 4	The licensee agreed to send the LPA a self certified written plan on how the medication will be handeled going forward.

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:

Joel Esquivel

LICENSING EVALUATOR NAME:

Janira Arreola

LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023

LIC809 (FAS) - (06/04)

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