336424391-2-26-2024-18-AS-JARA-D2TUAV-20240226142522

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336424391
Report Date: 02/26/2024
Date Signed: 02/26/2024 02:25:29 PM

Document Has Been Signed on 02/26/2024 02:25 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:	NEW HOPE RESIDENTIAL ELDER CARE, LLC		FACILITY NUMBER:	336424391
ADMINISTRATOR:	ANNIE JANE MIKENAS		FACILITY TYPE:	740
ADDRESS:	39520 BONAIRE WAY		TELEPHONE:	(951) 600-2941
CITY:	MURRIETA	STATE: CA	ZIP CODE:	92563
CAPACITY:	5	CENSUS: 4	DATE:	02/26/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Licensee, Jane Mikenas		TIME COMPLETED:	02:40 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) Janira Arreola conducted a required annual visit. LPA was greeted and was granted entry and met with Licensee, Jane Mikenas, who was informed of the purpose of the visit. At time of visit there were (4) clients and (4) staff present. The facility is a two story home with licensed capacity on the first floor with (3) bedrooms and (2) bathrooms. The facility does not have a pool or fire arms. The facility is a residential care facility for the elderly serving elderly ages 60 and above. LPA observed the following: Infection Control: LPA observed hand hygiene supplies, PPE equipment and cleaning supplies to do regular cleaning of the facility. The facility has a infection control plan on file. Physical Plant: Physical plant, floors, windows, and doors were observed to be clean and fixtures and furniture were present and in good repair. The facility's outdoor area was observed to be free of hazards. Laundry equipment was observed to be in good working condition. The carbon monoxide detector were operational. 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 food items.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2024

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: NEW HOPE RESIDENTIAL ELDER CARE, LLC	FACILITY NUMBER: 336424391
	VISIT DATE: 02/26/2024

NARRATIVE

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Record Review and Resident/Staff Files: LPA reviewed staff files and training along with CPR/First Aid. (1) on boarding staff did not have a health screening conducted, technical note was issued as all other staff had health screening and appointment had been previously booked for health screening. Licensee agreed to send LPA proof of the health screening when completed. Client files were reviewed and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: All client medication was locked in a hallway cabinet. LPA reviewed client medications and found that MARS and medication had discrepancies. LPA observe medication #1 (M1) was punched but not documented on MARS as given. Medication #2 (M2) was noted for morning, noon and evening, and LPA found all medication was punched out of bubble pack as given. Based on interview, the evening medications are given at 8pm, and at the time of inspection, 2:00pm, the evening medication had been punched as given. Based on staff interview, who admitted making an error, documentation and observation, the facility is being cited for

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing last fire drill conducted on 3/5/2023. This was cited and plan of correction was created with licensee.

An exit interview was conducted where a copy of this report, LIC809-D, LIC811, appeal rights and LIC9098 were reviewed and provided to, Licensee, Jane Mikenas.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/26/2024 02:25 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: NEW HOPE RESIDENTIAL ELDER CARE, LLC	FACILITY NUMBER: 336424391
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(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. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. 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:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above with the licensee's last documented drills being 3/5/2023, 11/2/2022 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/04/2024
	Plan of Correction
1 2 3 4	The licensee agreed to conduct a drill by the end of the month and send documentation to the LPA by the POC due date.

Type B

Section Cited

CCR

87465(a)(4)

(a) A plan for incidental medical and dental care...shall encourage routine medical and dental care...by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation,interview and record review, the licensee did not comply with the section cited above with medication decrepancies that were observed with M1 and M2 which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/04/2024
	Plan of Correction
1 2 3 4	The licensee agreed to send a self certified statement on medication procedure to be conducted to ensure medication errors do not reoccur. The licensee agreed to have a second staff verify MARS log and medication admisintration to minimize errors. This statement on procedure is due by the POC due date.

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: 02/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2024

LIC809 (FAS) - (06/04)

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