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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425204
Report Date: 05/03/2022
Date Signed: 05/03/2022 01:22:16 PM


Document Has Been Signed on 05/03/2022 01:22 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
RIVERSIDE, CA 92507



FACILITY NAME:TEMPLE PARK LIVINGFACILITY NUMBER:
336425204
ADMINISTRATOR:ESTA HOBBSFACILITY TYPE:
740
ADDRESS:40112 TENNYSON RD.TELEPHONE:
(951) 239-1557
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY:6CENSUS: 4DATE:
05/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Esta Hobbs, AdministratorTIME COMPLETED:
01:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Yolanda Delgado made an unannounced visit to the facility to conduct an annual inspection with an emphasis on infection control. LPA arrived at 11:30 AM, LPA was met by Caregiver Natalee White and explained the purpose of the visit. Present in the facility during time of visit were one (1) staff as well as four (4) residents. Administrator Esta Hobbs, Phillip Hobbs and one (1) caregiver arrived during the inspection. There are currently no cases of COVID-19 within the facility.

During today's visit, LPA toured the facility and made observations pertaining to the facility's infection control measures. LPA observed insufficient signage throughout the facility, insufficient hand hygiene supplies, insufficient cleaning and disinfecting provisions, and proper use of face coverings. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, PPE supplies need to be maintained at the facility, cleaning and disinfection provisions are in inadequate quantities, and that staff are trained in the proper use and disposal of PPE and overall infection control. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and residents for COVID-19, when and how to isolate/quarantine residents, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas. The facility also needs to maintain a plan to monitor resident(s) regularly for any changes in condition and to subsequently notify the resident(s) physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses.

Based on the observations made during today’s visit, two (2) deficiencies were cited per Title 22, Division 6, of the California Code or Regulations. An exit interview to review this report was conducted and a copy of this report and appeal rights was provided.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda DelgadoTELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2022
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 05/03/2022 01:22 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
RIVERSIDE, CA 92507


FACILITY NAME: TEMPLE PARK LIVING
FACILITY NUMBER: 336425204

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
97309(a)(1)
Storage Space: (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation during inspection the door to the laundry room was not locked and observed were two bottles of laundry detergent on the counter. Licensee failed to make sure cleaning detergents were secured and inaccessible to residents in care. The licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2022
Plan of Correction
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Licensee to agree to conduct and submit In-service for all staff on securing and locking up disinfectants and cleaning solutions inaccessible for clients while working in the facility. Proof to be submitted to the Department by 5pm on POC.
Type B
Section Cited
CCR
87468.2(a)
Additonal Personal Rights of Residents in Privately Operated Facilities: a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation and records review Licensee did not ensure COVID-19 Infection Control measures: COVID-19 screening protocols and practices for all staff, residents and visitors. The personal rights of persons in care to safe and healthful to the health, welfare, and safety of persons in care, as required by the CA Dept. of Public Health Guidance.
which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2022
Plan of Correction
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The licensee will obtain additional PPE, cleaning and disinfectant supplies and to be maintained at the facility, comply with screening protocols and practices for residents, staff and visitors. Proof of correction will be submitted to licensing by 5pm on POC.

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: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda DelgadoTELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2