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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336424582
Report Date: 07/02/2024
Date Signed: 07/02/2024 04:09:33 PM


Document Has Been Signed on 07/02/2024 04:09 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:PEACE AND JOY ELDER CARE IIFACILITY NUMBER:
336424582
ADMINISTRATOR:CECILE JIMENOFACILITY TYPE:
740
ADDRESS:26401 CHAMBERS AVENUETELEPHONE:
(951) 672-9958
CITY:SUN CITYSTATE: CAZIP CODE:
92586
CAPACITY:6CENSUS: 5DATE:
07/02/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Staff, Danilo LuceroTIME COMPLETED:
04:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit to the facility. The report documents deficiencies found during the time of the visit.

During the tour with staff LPA observed Resident #1 (R1), had a full bed rail, (2) chairs and a night stand surrounding the residents bed. The staff stated this is used from 1pm to 4pm everyday to keep the resident in her bed. In the morning the resident is placed in a Gerichair in the living room. Staff stated and showed LPA a foam mat that is used to surround the residents bed at night. The staff removed the furniture by the end of the visit and agreed to stop the use of the furniture to surround the resident's bed. A deficiency was cited and plan of correction was created with the administrator.

An exit interview was conducted with staff where this report along with deficiency page and appeal rights.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-233-6759
LICENSING EVALUATOR SIGNATURE:
DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 07/02/2024 04:09 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: PEACE AND JOY ELDER CARE II
FACILITY NUMBER: 336424582

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/03/2024
Section Cited
CCR
87468.1(a)(3)

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87468.1(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as... interfering with daily living functions...This requirement is not met as evidenced by:
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LPA had staff immediately remove furniture from the residents bed by the end of the visit. LPA spoke with administrator who agreed to conduct personal rights training to all staff including the administrator and send LPA proof by the POC due date.
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Based on observation and interview it was found that R1 was surrounded in their bed by furniture in order to keep R1 in their bed. This poses an immediate health safety or personal rights risk to residents in care.
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The administrator also agreed to meet with R1's responsible party and medical providers and create a written plan to mitigate R1's behavior and falls. This is also due by 7/16/2024.

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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: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-233-6759
LICENSING EVALUATOR SIGNATURE:
DATE: 07/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2