336425653-2-22-2024-18-AS-JARA-D2PT3H-20240222132223

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336425653
Report Date: 02/22/2024
Date Signed: 02/22/2024 01:22:32 PM

Document Has Been Signed on 02/22/2024 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	CROWN MANOR II		FACILITY NUMBER:	336425653
ADMINISTRATOR:	AGNES MARTINEZ		FACILITY TYPE:	740
ADDRESS:	34153 ALBACETE AVENUE		TELEPHONE:	(951) 246-7220
CITY:	MURRIETA	STATE: CA	ZIP CODE:	92563
CAPACITY:	6	CENSUS: 4	DATE:	02/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:10 AM
MET WITH:	Licensee and Administrator, Agnes Martinez		TIME COMPLETED:	01:35 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) Janira Arreola conducted a required annual visit. LPA was greeted and was granted entry and met with Licensee and Administrator, Agnes Martinez, who was informed of the purpose of the visit. At time of visit there were (4) residents and (3) staff present. The facility is a one story home with (5) bedrooms and (4) bathrooms with attached garage. The facility does not have a pool or fire arms. The facility is a residential care facility for the elderly serving elderly ages 60 and above. LPA observed the following: Infection Control: LPA observed hand hygiene supplies, PPE equipment and cleaning supplies to do regular cleaning of the facility. The facility has a infection control plan on file. Physical Plant: Physical plant, floors, windows, and doors were observed to be clean and fixtures and furniture were present and in good repair. The facility's outdoor area was observed to be free of hazards. Laundry equipment was observed to be in good working condition. The carbon monoxide detector was tested and operational during the visit. Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required food items.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024

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

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: CROWN MANOR II	FACILITY NUMBER: 336425653
	VISIT DATE: 02/22/2024

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
26
27
28
29
30
31
32

Record Review and Resident/Staff Files: LPA reviewed staff files and training along with CPR/First Aid. Resident files were reviewed and possessed all required paperwork, except for Resident #1 (R1) file which did not have an updated LIC602 with last LIC602 dated 9/10/2021, for resident with diagnosis of dementia. Deficiency and plan of correction was documented with licensee. One resident Resident #2 (R2) also did not have a written record of care on file. deficiency was cited and plan of correction was created with licensee.

Health Related Services/ Incidental Medical Services: All client medication was locked in a kitchen cabinet. LPA reviewed client medications and found that MARS and medication was accounted for and had required labeling.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing last fire drill conducted on 1/11/2024.

An exit interview was conducted where a copy of this report, along with LIC809-D page, LIC9098 form, and appeal rights were reviewed and provided to Licensee and Administrator, Agnes Martinez.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 02/22/2024 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CROWN MANOR II	FACILITY NUMBER: 336425653
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(c)(5)

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above with R1 whose LIC602 was last updated 9/10/2021 when R1 has a diagnoses of dementia which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/05/2024
	Plan of Correction
1 2 3 4	The licensee agreed to update the residents LIC602 and agreed to have all residents with dementia LIC602 updated every year. This is due by POC due date.

Type B

Section Cited

CCR

87467(a)(1)

(a) Prior to, or within two weeks of the resident’s admission, 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, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident’s preferences regarding the services provided at the facility. (1) At a minimum the written record shall include the date of the meeting, name of individuals who participated and their relationship to the resident, and the agreed-upon services to be provided to the resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above with R2 who did not have a current record of care on file and did not have one to show the licensing agency during the visit which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/05/2024
	Plan of Correction
1 2 3 4	The licensee agreed to document a plan of care for R2 and provide a copy to LPA 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 Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024

LIC809 (FAS) - (06/04)

Page: 4 of 4