336425651-1-27-2025-18-AS-YDEO-DDC558-20250127183840

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336425651
Report Date: 01/27/2025
Date Signed: 01/27/2025 06:38:55 PM

Document Has Been Signed on 01/27/2025 06:38 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:	EAGEL TIME CARE FACILITY		FACILITY NUMBER:	336425651
ADMINISTRATOR/ DIRECTOR:	JUAN CORNELL		FACILITY TYPE:	740
ADDRESS:	1622 PALERMO DRIVE		TELEPHONE:	(562) 685-4610
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92507
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	01/27/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:50 PM
MET WITH:	Juan Cornell, Administrator		TIME VISIT/ INSPECTION COMPLETED:	06:45 PM

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) Yolanda Delgado arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction, visit purpose and provided the facility caregiver with LPA identification and business card. Resident record review began- Five (5) records were reviewed. LPA reviewed for admission agreement, medical assessment-1 missing and TB test results-1 missing, consent forms, identification and emergency information, appraisal-5 missing, needs and service plans, centrally stored medication/destruction records-not being updated, safeguard for personal property/valuables, and personal rights notification. This facility is meeting is not meeting documentation requirements. Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. The home is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured 111.0 degrees F. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals in the home. All indoor passageways are free of obstruction, outdoor passage way is not free from obstruction. A locked area is provided for medications and sharp objects. LPA verified there is a telephone working at this location. Food Service- Food supply meets the requirement of one week supply of nonperishable and 2 day supply of perishables food on hand. A sample menu is provided, foods are dated to assure safety. Food prep areas are clean and organized. Stove interior needs cleaning LPA began review of employee records- Three (3) records were reviewed. LPA reviewed employee record for first aid certification, fingerprint clearance, personnel/job application, health screening-1 missing and TB test results-1 missing, criminal record statement, employee rights, training verification-not available to be reviewed, and current administrator certification. CPR and requirements have been met. The facility employs enough staff to maintain cleanliness and meet the needs of the clients in care. Administrator certification is present and current. (Continued on next page)

Jazmond D Harris	TELEPHONE: (951) 248-0318
Yolanda Delgado	TELEPHONE: (951) 203-2990
	DATE: 01/27/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025

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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: EAGEL TIME CARE FACILITY	FACILITY NUMBER: 336425651
	VISIT DATE: 01/27/2025

NARRATIVE

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CPR and requirements have not been met. The facility employs enough staff to maintain cleanliness and meet the needs of the clients in care. Administrator certification is present and current.

LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. The facility has not exceeded its capacity limitation and the structure remains unchanged according to the approved floor plan. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguishers was last serviced 6/1/2022. The facility is conducting emergency disaster drills. The last disaster drill was conducted on 11/17/2024.

LPA allocated time to prepare this report for delivery.

Based on the information received during this visit today, there are 12 deficiencies is being cited per Title 22, Division 6 of The California Code of Regulations.

This report, LIC809-D, Appeal Rights, LIC 421IM for Civil penalties for $500 will be issued was reviewed with and copies provided to the facility representative at the time of the exit interview.

LPA has requested updates to the following documents to be submitted to the CCLD by 01/31/2025: LIC 500

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda Delgado	TELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/27/2025 06:38 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: EAGEL TIME CARE FACILITY	FACILITY NUMBER: 336425651
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87202(a)

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in fire extinguisher's tag for service is stamped 6/11/2022 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/28/2025
	Plan of Correction
1 2 3 4	Licensee will replace expired fire extinguisher by POC due date.

Type A

Section Cited

CCR

87309(a)

Storage Space and Access

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in Bleach container and Ajax container observed in the first floor restroom inside an unsecured cabinet under the sink which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/28/2025
	Plan of Correction
1 2 3 4	Licensee will remove items from the cabinet, ensure all cleaning solutions, poisonous substances that pose a danger to residents are locked in a storage area and not left unattended if outside of the locked storage and conduct training with all staff and submit training sheet by 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.

Jazmond D Harris	TELEPHONE: (951) 248-0318
Yolanda Delgado	TELEPHONE: (951) 203-2990
	DATE: 01/27/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/27/2025 06:38 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: EAGEL TIME CARE FACILITY	FACILITY NUMBER: 336425651
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87303(a)

Maintenance and Operation

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA Delgado's observation, interview, the licensee did not comply with the section cited above in 2nd floor restroom light is broken, the stove interior is dirty which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/24/2025
	Plan of Correction
1 2 3 4	Licensee will repair broken light and ensure stove interior is cleaned by POC due date.

Type B

Section Cited

CCR

87303(c)

Maintenance and Operation

(c) All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA Delgado's observation and interview the licensee did not comply with the section cited above in [count] out of two exterior window screens has tears which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/24/2025
	Plan of Correction
1 2 3 4	Licensee will replace the two torn window screen and send an invoice or pictures to LPA by 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.

Jazmond D Harris	TELEPHONE: (951) 248-0318
Yolanda Delgado	TELEPHONE: (951) 203-2990
	DATE: 01/27/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/27/2025 06:38 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: EAGEL TIME CARE FACILITY	FACILITY NUMBER: 336425651
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87307(d)(6)

Personal Accommodations and Services

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA Delgado's observation and interview, the licensee did not comply with the section cited above in outdoor passageway is not free of obstruction with overgrown grass which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/24/2025
	Plan of Correction
1 2 3 4	Licensee will free obstruction of outdoor passageway and email picture to LPA by POC due date.

Type B

Section Cited

CCR

87412(d)

Personnel Records

(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in no documentation was available of training in Administrators files which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/24/2025
	Plan of Correction
1 2 3 4	Administrator will email LPA copies of recertification trainings by 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.

Jazmond D Harris	TELEPHONE: (951) 248-0318
Yolanda Delgado	TELEPHONE: (951) 203-2990
	DATE: 01/27/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/27/2025 06:38 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: EAGEL TIME CARE FACILITY	FACILITY NUMBER: 336425651
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

HSC

1569.69(a)

Other Provisions

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in no training documents were observed for staff in their files which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/24/2025
	Plan of Correction
1 2 3 4	Licensee will email copies of staff's training records to LPA by POC due date.

Type B

Section Cited

CCR

87465(h)(5)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in an inhaler was observed and was unable to verify the medication belonged to which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/24/2025
	Plan of Correction
1 2 3 4	Licensee will ensure all prescribed medications for residents in care remain in its orginal received container and conduct training with all staff and email training sheet to LPA by 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.

Jazmond D Harris	TELEPHONE: (951) 248-0318
Yolanda Delgado	TELEPHONE: (951) 203-2990
	DATE: 01/27/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/27/2025 06:38 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: EAGEL TIME CARE FACILITY	FACILITY NUMBER: 336425651
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87465(d)(3)

Incidental Medical and Dental Care Services

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in no documentation was observed for PRN medication for resident in which 3/30 pills were missing which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/24/2025
	Plan of Correction
1 2 3 4	Licensee will ensure documenting requirements are being met for all PRN medications for all clients in care and conduct training with staff and email training sheet to LPA by POC due date.

Type B

Section Cited

CCR

87463(h)

Reappraisals

(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in no reappraisal documentation was observed in all resident's files which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/24/2025
	Plan of Correction
1 2 3 4	Licensee will email copies of current reappraisals of residents to LPA by 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.

Jazmond D Harris	TELEPHONE: (951) 248-0318
Yolanda Delgado	TELEPHONE: (951) 203-2990
	DATE: 01/27/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025

LIC809 (FAS) - (06/04)

Page: 7 of 8

Document Has Been Signed on 01/27/2025 06:38 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: EAGEL TIME CARE FACILITY	FACILITY NUMBER: 336425651
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87463(h)(1)

Reappraisals

(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. (1) Documentation of the annual routine visit, such as a visit summary, shall be added to the resident's record. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in no documentation was observed of an annual routine visit which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/24/2025
	Plan of Correction
1 2 3 4	Licensee will obtain documentation of residents annual routine visit with a licensed medical professional and ensure that every twelve months a resident receives an annual routine visit wilth a licensed medical professional. Licensee will email copies of documentation of current annual routine visit to LPA by POC due date.

Type B

Section Cited

HSC

1569.695(a)(2)

Other Provisions

(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA Delgado's observation and interview, the licensee did not comply with the section cited above in no emergency water was observed and emergency food was not separate from regular house food which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/24/2025
	Plan of Correction
1 2 3 4	Licensee will obtain emergency water and separate emergency food for residents and staff for 72 hours and email pictures to LPA by 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.

Jazmond D Harris	TELEPHONE: (951) 248-0318
Yolanda Delgado	TELEPHONE: (951) 203-2990
	DATE: 01/27/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025

LIC809 (FAS) - (06/04)

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