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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425049
Report Date: 03/07/2024
Date Signed: 03/07/2024 03:13:35 PM


Document Has Been Signed on 03/07/2024 03:13 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
, CA 92507



FACILITY NAME:ALICIA PINES RESIDENTIAL CAREFACILITY NUMBER:
336425049
ADMINISTRATOR:OFELIA HOUSEFACILITY TYPE:
740
ADDRESS:6675 VALLEY DRIVETELEPHONE:
(951) 353-8900
CITY:RIVERSIDESTATE: CAZIP CODE:
92505
CAPACITY:6CENSUS: 3DATE:
03/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Licensee/Administrator Ofelia HouseTIME COMPLETED:
03:35 PM
NARRATIVE
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On 03/07/2024 at 12:05 PM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Brown met Licensee/Administrator Ofelia House and was granted entry to the facility. At the time of the visit there was one (1) staff present, and three (3) residents present. LPA Brown explained the purpose of the visit to Licensee/Administrator House.

The facility is a six (6) bedroom, two (2) bathroom home with a kitchen/dining area, living room, laundry room and detached garage. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) residents of which (6) can be non-ambulatory residents and one (1) may be bedridden resident. The facility has three (3) Hospice Waiver. The current census is three (3) residents. LPA Brown was accompanied by Licensee/Administrator House (S1) to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). LPA Brown observed no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA Brown inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA Brown observed grab bars and non-skid mat in the resident shared bathroom.

LPA Brown observed sufficient furniture and lighting throughout the facility. LPA Brown measured and observed the water temperatures in the bathroom to be at 108 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarm. Posters such as personal rights, the CCLD complaint poster, Ombudsman poster and the disaster plan were posted in a common area.

***Continuation in LIC809C ***

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2024
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 5


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
, CA 92507
FACILITY NAME: ALICIA PINES RESIDENTIAL CARE
FACILITY NUMBER: 336425049
VISIT DATE: 03/07/2024
NARRATIVE
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There is a steel cabinet with the resident’s medications locked in the activity area/office area. First Aid kit and first Aid book were observed at the facility.

Food Service: Seven (7) days non-perishable and two (2) days perishable food supply observed at the facility.

Care & Supervision: The facility has an administrator present in the facility. However, LPA Brown observed no staff scheduled to work at night (NOC) shift and the facility have two (2) dementia residents. Deficiency will be issued. LPA Brown explained to Licensee/Administrator House that the facility must have at least one(1) night staff person awake, and on duty due to the facility having dementia residents.

Record Review: LPA reviewed three (3) resident files for admission agreements, updated physician reports, and resident appraisals. LPA Brown observed Resident #1 (R1) Admission Agreement without Responsible Party Signature. Deficiency will be issued. Also, LPA Brown observed R1 without updated Physician Report as required for dementia resident. Deficiency will be issued. LPA reviewed two (2) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with Tuberculosis (TB) test result. LPA Brown observed staff files reviewed were complete. Furthermore, two (2) residents medication were audited and LPA Brown observed no issue. In addition, Licensee/Administrator House reported to LPA Brown the facility's liability insurance expired on 02/2024. Deficiency will be issued.

An exit interview was conducted where this report (LIC809), LIC809D and Appeal Rights were discussed and provided to Licensee/Administrator Ofelia House.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 03/07/2024 03:13 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: ALICIA PINES RESIDENTIAL CARE
FACILITY NUMBER: 336425049

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(c)(4)(A)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident's physical, social, emotional, safety and health care needs as identified in his/her current appraisal. (A) In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal or observation to require awake night supervision.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that there's a staff scheduled to work night (NOC) shift for night supervision to residents with dementia which which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/08/2024
Plan of Correction
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LIcensee stated to to train all staff on CCR 87705(c)(4)(A) and submit proof of Training Log to LPA Brown at Plan of Correction (POC) due date.
Licensee stated to submit updated LIC500 Personnel Report or staff schedule indicating night shift staff working at the facility to LPA Brown at POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 03/07/2024 03:13 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: ALICIA PINES RESIDENTIAL CARE
FACILITY NUMBER: 336425049

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not maintaining the required liability insurance for the facility poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2024
Plan of Correction
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Licensee stated to submit proof of the required liability insurance for the facility to LPA Brown at Plan of Correction (POC) due date.
Type B
Section Cited
CCR
87507(c)
Admission Agreements
(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not having Resident #1 (R1) Responsible Party signed R1's Admission Agreement in R1's facility file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2024
Plan of Correction
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Licensee stated to have R1's Responsible Party signed R1's Admission Agreement and submit proof to LPA Brown at 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: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 03/07/2024 03:13 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: ALICIA PINES RESIDENTIAL CARE
FACILITY NUMBER: 336425049

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not having an updated Physician Report for Resident #1 (R1) as required for resident with dementia which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2024
Plan of Correction
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Licensee stated to have R1's updated Physician Report as required for dementia resident and submit proof to LPA Brown at Plan of Correction (POC) due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5