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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425448
Report Date: 09/11/2024
Date Signed: 09/11/2024 12:21:11 PM


Document Has Been Signed on 09/11/2024 12:21 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:PEBBLE BROOK SENIOR HOME CAREFACILITY NUMBER:
336425448
ADMINISTRATOR:WINSTON FALCONFACILITY TYPE:
740
ADDRESS:33722 PEBBLE BROOK CIRCLETELEPHONE:
(951) 303-0253
CITY:TEMECULASTATE: CAZIP CODE:
92592
CAPACITY:6CENSUS: 6DATE:
09/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Winston Falcon, Administrator TIME COMPLETED:
12:35 PM
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On 09/11/24 at 10:20am Licensing Program Analyst (LPA) Javina George to conduct an unannounced annual visit 1 year required visit. LPA was greeted an granted entry by Caregiver Maria Guiterrez, where LPA explained the purpose of the visit. The Administrator Winston Falcon had accompanied a resident to an appointment and arrived at 11:32am.

The facility is approved for six (6) bedridden residents, aged 60 and older. The facility has an approved dementia plan of operation and a hospice waiver for 4 residents. There are currently (2) residents receiving hospice services, in addition to (2) residents receiving home health services.

LPA conducted a tour of the interior and exterior areas of the facility. The facility is a single story home consisting of 5 resident bedrooms, and 3 bathrooms, laundry room, living room, kitchen, garage and backyard. The resident bedrooms beds were observed to have clean linens, a chest of drawers, and night stand. The facility was observed to be clean, and clutter free. The hot water temperature was tested and measured 112-113 degrees Fahrenheit within regulatory limits. The facility has (2) fully charged fire extinguishers, with the tags in tact.

The medications are stored in a locked cabinet in the hallway, across from the laundry room. The smoke and carbon monoxide detectors were tested and observed to be operable. The facility conducts emergency disaster drills on a quarterly basis, the last drill was conducted in June 2024, a drill is due by the end of the month in order to remain in compliance.

LPA conducted a records review and observed for both staff and residents. All staff present were observed to have obtained criminal record clearance and to be associated to the facility, as well as to possess valid CPR certification. The administrator Winston was observed to have a valid administrator's certificate that expires 07/24/25. The resident files had the required documentation such as admissions agreement, medical and medical assessment.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2024
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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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: PEBBLE BROOK SENIOR HOME CARE
FACILITY NUMBER: 336425448
VISIT DATE: 09/11/2024
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The facility food supply was observed to meet the requirements of a 2 day supply of perishable and a 7 day supply of non perishable food items. Based on today's inspection no deficiencies were issued in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8).


An exit interview was conducted and a copy of this report was provided to Winston Falcon, Administrator.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024
LIC809 (FAS) - (06/04)
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