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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336424582
Report Date: 08/16/2024
Date Signed: 08/19/2024 09:54:28 AM

Document Has Been Signed on 08/19/2024 09:54 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:PEACE AND JOY ELDER CARE IIFACILITY NUMBER:
336424582
ADMINISTRATOR/
DIRECTOR:		CECILE JIMENOFACILITY TYPE:
740
ADDRESS:26401 CHAMBERS AVENUETELEPHONE:
(951) 672-9958
CITY:SUN CITYSTATE: CAZIP CODE:
92586
CAPACITY: 6CENSUS: 5DATE:
08/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Favieruth Jimeno, AdministratorTIME VISIT/
INSPECTION COMPLETED:
10:45 AM
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On 08/16/2024 Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct an annual inspection/1 year required visit. LPA met with Administrator Favieruth Jimeno, and explained the purpose of the visit. The facility is licensed to serve (6) non ambulatory, of which 1 may be bedridden in bedroom #3 or #4 only. The facility has an approved hospice waiver for 2. The facility currently has (2) residents that are receiving hospice services.

The home is a single story structure consisting of 4 resident, and 1staff bedroom, and 2 bathrooms, kitchen, garage, backyard, dining area and family room. There are no pools or bodies of water on the premises. The hot water temperature was tested and measured at 107.6 degrees Fahrenheit. The facility was observed to be clean and clutter free, with the pathways being free from obstruction. The facility was observed to have the required postings such as personal rights, CCL complaint poster LTCO poster, emergency disaster plan. The food supply was adequate as the facility was observed to have a 2 day supply of perishable and a 7 day supply of nonperishable food items. The facility has an ample supply of linen, hygiene and incontinent supplies as well as Personal Protective Equipment (PPE). The facility has a mitigation plan on file as of 04/16/21.

The medications and sharp objects are stored in locked cabinets located inside the kitchen. The medications present were labeled and in their original containers or bubble packs. Medications are being given as prescribed as evidenced by the Medication Authorization Record (MAR). The facility has a fully charged fire extinguisher, and the smoke and carbon monoxide detectors were tested and were observed to be operable. The facility is required to conduct the emergency disaster drills on a quarterly basis, the last drill was conducted on 08/09/24. There are no known guns or ammunition on the premises.
A records review was conducted on both staff and resident files, each file reviewed (2) residents were observed to have a medical assessment, and appraisals. Staff records reviewed (3) were observed to have current CPR certification, with all staff having obtained proper fingerprint clearance and to be associated to
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2024
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: PEACE AND JOY ELDER CARE II
FACILITY NUMBER: 336424582
VISIT DATE: 08/16/2024
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the facility. The Administrator was observed to possess a valid administrator certificate, that expires April 2025.

The facility has an ample supply of personal protective equipment. There are no known guns or ammunition on the premises. LPA conducted a file review and as of 08/01/24, and 08/16/24 and observed for the annual
licensing fees have not been paid, as they are due by today 08/16/24. During today's visit LPA followed up regarding the fees, and provided the PIN so that the fees could be paid electronically.

During today's visit LPA obtained a copy of updated liability insurance policy, that expires on 05/15/25.

Based on today's inspection no citations were issued and the facility was observed to be in compliance with the California Code of Regulations (Title 22, Division 6, Chapter 8).

An exit interview was conducted and a copy of this report, was provided to Administrator Favieruth Jimeno.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024
LIC809 (FAS) - (06/04)
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