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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425204
Report Date: 01/17/2024
Date Signed: 01/17/2024 01:09:26 PM


Document Has Been Signed on 01/17/2024 01:09 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: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: 5DATE:
01/17/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Licensee, Esta HobbsTIME COMPLETED:
01:15 PM
NARRATIVE
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On January 17, 2024, Community Care Licensing (CCLD) held an informal meeting conducted in the Riverside Adult and Senior Care Regional Office. In attendance was Licensing Program Manager (LPM) Rikesha Stamps, Licensing Program Analysts (LPA)s, Janira Arreola and Crystal Colvin, and Licensee, Esta Hobbs.

The purpose of the meeting is to discuss the sale of the following facilities; Temple Court Senior Care #336413282, Temple Gardens #336425854, Temple Heights #331880725, Temple Park Living #336425204. Listed licensee and administrator Esta Hobbs.

During today’s meeting Licensee confirmed with the CCLD that the facilities listed above had been sold on September 01, 2023, to RNZ Quality Care, Muhammed Zohar Alvi. The Licensee confirmed that they had not notified the department in writing about the sale of the facilities. The department staff verified no record of an application for the change in ownership was submitted.

Association for the new owners, Staff #1 (S1), Staff #2 (S2), and Staff #3 (S3) were not found on the facilities listed above.

Licensee Esta Hobbs is currently operating the facilities and is providing care and supervision to facility residents. Information obtained regarding the residents was provided.

LPM Stamps addressed concerns of facility operations such as.

· staff association

· knowledge of the Title 22 regulations

· knowledge of the H&S (Health and Safety)

· record keeping

· Discussion of recent substantiated Priority One complaint and plan of correction

SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2024
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 4


Document Has Been Signed on 01/17/2024 01:09 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: TEMPLE PARK LIVING
FACILITY NUMBER: 336425204

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/24/2024
Section Cited
CCR
87109(b)

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(b) The licensee shall notify the licensing agency…in writing…in all cases at least thirty (30) days prior to the transfer of...business, or at the time that a bona fide offer is made, whichever period is longer..
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The licensee agreed to send written notification of sale and recognize they has missed the deadline to do so. This is due by the POC due date.
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The requirement was not met as evidenced by: Based on interview, it was revealed that the licensee had not notified the licensing agency within the required time frame of the sale of the facility. This posed a potential health, safety or personal rights risk to residents in care.
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Type B
01/24/2024
Section Cited
HSC1569.191(b)

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(b) Except as provided in subdivision (e)… (2) The prospective buyer shall submit an application for a license…within five days of the acceptance of the offer by the seller.
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The licensee agreed to send proof to the LPA of application for change of ownership by the POC dued ate.
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This requirmen was not met as evidenced by: Based on interviews and records review, an application for change in ownership has not been received by he licensing agency within he required time frame. This poses a potential health, safety, or personal rights risk to residents in care.
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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: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4


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: TEMPLE PARK LIVING
FACILITY NUMBER: 336425204
VISIT DATE: 01/17/2024
NARRATIVE
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Licensee was provided resources from the CCLD transparency website and was encouraged to adhere to the Title 22 Regulations on maintaining substantial compliance.

Licensee confirmed she will continue to maintain current operations until the new owners become licensed.

Deficiencies was cited under the California Code of Regulations Title 22 and Health and Safety Code (H&S) for transferability of the license, application submission for change of ownership, and lack of association for the three staff members.

An exit interview was conducted with Licensee Esta Hobbs, who was provided a copy of this report along with copies of the LIC809C, LIC809D, LIC811, LIC9102 and appeal rights.

SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 01/17/2024 01:09 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: TEMPLE PARK LIVING
FACILITY NUMBER: 336425204

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/18/2024
Section Cited
CCR
87355(e)(2)

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87355 Criminal Record Clearance(e)All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance…
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The licensee agreed to associate S1 S2 and S3 to the faciliy and send proof to LPA by POC due date.
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This requirment was not met as evidenced by: Based on interviews and record review, it was found S1, S2, and S3 were not associated to the facility. This poses an immediate health, safety and personal rights risk to residents in care.
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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: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4