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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336424485
Report Date: 10/17/2023
Date Signed: 10/17/2023 01:07:00 PM

Document Has Been Signed on 10/17/2023 01:07 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:MORENO VALLEY GUEST HOME IIFACILITY NUMBER:
336424485
ADMINISTRATOR:NOYA JACKSONFACILITY TYPE:
735
ADDRESS:15370 LAS ROSAS AVENUETELEPHONE:
(951) 242-1316
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92551
CAPACITY: 6CENSUS: 0DATE:
10/17/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:37 AM
MET WITH:Michael Curry, AdministratorTIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jesse Gardner arrived unannounced to conduct a health and safety visit. Upon arrival, LPA met with Administrator Michael Curry and was granted entry. LPA then conducted a tour of the facility accompanied by Mr. Curry. LPA found that the 2 clients who live in the facility, are currently at their day programs.

LPA conducted a tour of the exterior and interior of the facility. LPA found an unlocked door leading to the garage with chemicals, which was not able to be locked due to a bungee cord keeping the door open. LPA then found an unlocked door under the sink which had knives, as well an an unlocked medication cabinet. LPA also found that the refrigerator was held together by a locking mechanism. LPA inquired about the lock, and Administrator Curry stated that Client #1 (C1) has recently been getting up at night and taking food out of the refrigerator. Technical Violations were issued for the aforementioned discrepancies. No other immediate health and safety risks to residents in care were observed.

On 8/15/23, according to the Administrator, Client #2 (C2) was eating dinner, and had began taking a long time to eat, approximately 3 hours, moving slowly. Prior to eating dinner, when C2 arrived to the facility from the day program, a day program representative told staff that C2 "looked off". At that point, staff took C2's vital's, and they returned normal. C2's primary care physician was called, and physician said to call 911 to have C2 evaluated (for medical response).

*Continued on LIC809C
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2023
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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Document Has Been Signed on 10/17/2023 01:07 PM - It Cannot Be Edited


Created By: Jesse Gardner On 10/17/2023 at 11:55 AM
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: MORENO VALLEY GUEST HOME II
FACILITY NUMBER: 336424485

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/24/2023
Section Cited
CCR
80061(b)(1)(A)

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Reporting Requirements: (b) Upon the occurrence.. of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written.. specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence... (1) Events reported shall include the following:(A) Death of any client from any cause. This requirement was not being met as evidenced by:
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Licensee agrees to conduct in-service training regarding the cited regulation, and provided proof of such by POC date.
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Based on interview with Adminstrator, CCL was not notified of the client passing until 10/12/23. Tbis poses a potential health and safety risk to clients in care.
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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 Stamps
LICENSING EVALUATOR NAME:Jesse Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2023


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: MORENO VALLEY GUEST HOME II
FACILITY NUMBER: 336424485
VISIT DATE: 10/17/2023
NARRATIVE
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C2 had delayed responses when asked questions, which, according to the Administrator, was not normal. C2 went to Riverside University Health System (RUHS), and on 8/23/23, C2 arrived to Jurupa Hills Post Acute (SNF). SNF staff contacted the Administrator to state that C2 had passed away on 10/5/23. The Administrator stated that notification was made to the Department (CCL) on 10/12/23 via written document. LPA explained to the Administrator that the passing of C2 should have been reported to the Department the following day, with a written report following within 7 days. Deficiency cited.

During LPA's visit, LPA reviewed C1's file and obtained copies of the following: ID/emergency Information, admission agreement, Physician's reports, Psychiatric notes, resident appraisal, appraisal needs and service plan, progress notes, medication records (MARs) for 07/01/2023-10/05/2023, personal property records, weight record, and laboratory paperwork. LPA also requested a copy of C1s death certificate when it is made available.

An exit interview was conducted where a copy of this report was discussed with along with a copy of the LIC809C, LIC809D, and Appeal Rights were provided.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023
LIC809 (FAS) - (06/04)
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