<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425145
Report Date: 02/12/2024
Date Signed: 02/12/2024 11:10:45 AM

Document Has Been Signed on 02/12/2024 11:10 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:APOSTOL FAMILY HOME LLC IIFACILITY NUMBER:
336425145
ADMINISTRATOR:APOSTOL, ROSAMILAFACILITY TYPE:
735
ADDRESS:24922 BRANCH ST.TELEPHONE:
(951) 208-0978
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY: 6CENSUS: 4DATE:
02/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jamie Apostol - LicenseerTIME COMPLETED:
11:30 AM
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) Crystal Colvin arrived at the facility unannounced for the purpose of conducting the annual inspection. LPA Colvin met with Licensee Jamie Apostol and informed him of the purpose of today's inspection. Below is a summary of what was observed:

Infection Control: LPA Colvin observed that the facility has an updated Infection Control Plan on file and is demonstrating best practices in the facility to maintain a healthy environment for staff and residents. Such measures include: soap and paper towels at hand washing stations, hand washing guides posted, and monitoring the residents and staff for symptoms of infectious diseases.

Physical Plant: LPA Colvin toured the facility and observed that there a sufficient bedrooms and bathrooms for both staff and residents. LPA Colvin observed the required furniture and linen to be present and in good condition in resident bedrooms. LPA Colvin observed the facility to be a comfortable temperature and that the hot water in the bathroom faucets measured at 110.3 degrees. LPA Colvin did not observe any obstructions to emergency exits or hallways/walkways. LPA Colvin tested the facility's carbon monoxide alarm and smoke detectors and found them to be operational. LPA Colvin observed that sharp objects like knives and dangerous chemicals were locked in a cabinet in the kitchen, away from residents' reach.

Operational Requirements: LPA Colvin observed the facility to be operating within their licensed capacity of 6 residents, 4 of which may be ambulatory and 2 non-ambulatory.

Staffing & Staff Records: LPA Colvin confirmed that there are sufficient staff present to meet the needs of residents. LPA Colvin additionally confirmed that there is an Administrator present daily. LPA Colvin confirmed staff have criminal record clearance and have training to perform their required duties. Staff present have current CPR/First Aid Certification.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 02/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/12/2024
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 3
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: APOSTOL FAMILY HOME LLC II
FACILITY NUMBER: 336425145
VISIT DATE: 02/12/2024
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
26
27
28
29
30
31
32
Resident Records: LPA Colvin reviewed the files for all 4 current residents and confirmed that they have the required information present in their files, including Physician's Report, Admissions Agreement, and current Needs & Services Plan. LPA Colvin was unable to interview residents during today's inspection as they were all out in the community.

Food Services: LPA Colvin observed the facility to have the required amount of perishable and non-perishable food. LPA Colvin observed the kitchen and dining area to be maintained in a clean and healthful manner. Sufficient dishware and silverware was present for residents use.

Incidental Medical Services: LPA Colvin observed that resident medication is locked in the staff room and inaccessible to residents without staff supervision. LPA Colvin confirmed that the facility is not retaining any residents with prohibited health conditions. LPA Colvin observed staff training records in resident files for resident(s) with additional specific health concerns with plans on how the facility staff will meet those needs. Licensee Jamie Apostol confirmed that the facility has doctors that come to the facility every month to provide services and evaluations of the residents, and this was reflected in the resident files.

Emergency Disaster Preparedness: LPA Colvin confirmed that the facility has an Emergency Disaster Plan on file with Licensing, but the facility's binder with the plan and quarterly disaster drills was not present at the facility and available for LPA Colvin to review. LPA Colvin was unable to verify that quarterly disaster drills are being conducted and therefore will be issuing a deficiency.

An exit interview was conducted with Licensee Jamie Apostol and a copy of this report, LIC809D, and appeal rights were provided.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/12/2024 11:10 AM - It Cannot Be Edited


Created By: Crystal Colvin On 02/12/2024 at 10:57 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: APOSTOL FAMILY HOME LLC II
FACILITY NUMBER: 336425145

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80023(d)(2)

Disaster and Mass Casualty Plan: (d) Disaster drills shall be conducted at least every six months. (2) The drills shall be documented and the documentation maintained in the facility for at least one year. This requirement was not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 2 out fo 2 Emergency Disaster Drills, which poses a potential safety risk to persons in care. LPA Colvin was unable to confirm that the facility is conducting the required Emergency DIsaster Drills due to the file for the drills and the documented drills not being present at the facility during today's inspection
POC Due Date: 02/29/2024
Plan of Correction
1
2
3
4
Licensee agrees to provide LPA Colvin with a copy of the facility's last year's worth of Emergency Disaster Drills and also agrees to maintain a record of these drills at the facility. Plan of Correction due by 2/29/24
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2024


LIC809 (FAS) - (06/04)
Page: 3 of 3