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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425398
Report Date: 03/28/2024
Date Signed: 03/28/2024 04:03:38 PM


Document Has Been Signed on 03/28/2024 04:03 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:ANNA'S PARK HAVENFACILITY NUMBER:
336425398
ADMINISTRATOR:ANNA ESTANIELFACILITY TYPE:
740
ADDRESS:3911 PARK AVENUETELEPHONE:
(951) 658-6223
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY:6CENSUS: 3DATE:
03/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Anna Estaniel, AdministratorTIME COMPLETED:
04:10 PM
NARRATIVE
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Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to complete a required annual inspection. The LPA met with Administrator, Anna Estaniel, and informed her of the purpose for her visit.

Physical Plant: The facility consists of four (4) resident bedrooms, one staff bedroom, one dining area, two living spaces, a kitchen, a laundry area, a garage space, and a covered patio with sufficient seating and space for activities. The facility's pool was observed to be inaccessible to unauthorized individuals. According to Administrator Estaniel, there are no weapons stored in the home. The facility is being maintained at a comfortable temperature. All indoor areas were observed to be free of debris and other trash. There are grab bars for the toilet and shower used by residents. Resident shower has a non-skid mat present. The carbon monoxide and smoke detectors were tested by facility staff and were observed to be in operating condition. LPA observed about three chemicals/cleaners to be accessible in restroom #2. A citation will be issued.

Medication Review: A medication review was completed for Resident Three's (R3's) medications. Medications were maintained separate from other resident's medications.

Staff Records: The LPA reviewed staff training and observed first aid and CPR training to be available.

Resident Records: The LPA reviewed resident records. A Pre-Admission Appraisal and Admission Agreement was observed on file for R3. A written record of care was not observed on file for R3. When reviewing resident hospice files the LPA observed no hospice care plan for Resident One (R1). Citations will be issued.

An exit interview was conducted; this report was reviewed with Administrator Estaniel and a copy was provided, along with instructions on appeal rights, and the LIC 811.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/28/2024 04:03 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: ANNA'S PARK HAVEN
FACILITY NUMBER: 336425398

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)
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 observation, the licensee did not comply with the section cited above in that about three chemicals/cleaners were observed to be accessible in bathroom #2. This poses a potential health and safety risk to persons in care.
POC Due Date: 03/28/2024
Plan of Correction
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The Administrator immediately removed the chemicals/cleaners and placed them in a secure area at time of inspection.
Type B
Section Cited
CCR
87463(C)
Other Provisions
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one out of one residents who did not have a written record of care on file. This poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 04/30/2024
Plan of Correction
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The Administrator stated a written record of care will be completed for R3 and a copy provided to the Department by the 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: Rikesha StampsTELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 03/28/2024 04:03 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: ANNA'S PARK HAVEN
FACILITY NUMBER: 336425398

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87633(b)
Hospice Care for Terminally Ill Residents
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one out of one hospice care plan for one out of one residents. R1 did not have a complete hospice care plan on file for R1. This poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 03/28/2024
Plan of Correction
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The Administrator obtained a copy of R1's Hospice Care Plan from the Hospice agency during the visit.
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: Rikesha StampsTELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3