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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425854
Report Date: 05/20/2022
Date Signed: 05/20/2022 12:29:07 PM


Document Has Been Signed on 05/20/2022 12:29 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:TEMPLE GARDENSFACILITY NUMBER:
336425854
ADMINISTRATOR:HOBBS, ESTAFACILITY TYPE:
740
ADDRESS:40023 TEMPLE COURTTELEPHONE:
(951) 249-9860
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY:6CENSUS: 6DATE:
05/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Licensee- Esta HobbsTIME COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA), Janira Arreola made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA was greeted and granted entry by S1 and met with licensee Esta Hobbs, who was informed of the purpose of the visit. At the time of visit there was 4 staff and 6 residents present. The facility currently has zero positive or suspected Covid-19 cases.

During today's visit, LPA toured the facility and made observations regarding the infection control measures that the facility has implemented. LPA observed Covid-19 postings. A single entry point was designated where symptoms screenings and temperature checks occur daily for all visitors, residents, and staff. The facility had a plan in place to monitor residents regularly for any changes in condition. The facility had an adequate amount of hand hygiene supplies (soap, hand sanitizer, paper towels) in all restrooms. Common areas such as dining rooms and activity rooms have been modified with social distancing and masking policies. There are designated isolation rooms and a plan in place to monitor and attend to those in the isolation rooms. LPA observed a sufficient 30-day supply of PPE equipment. The facility also has a designated infection control lead and a plan in place to clean and disinfect the highly touched surfaces. LPA was able to review the LIC808 at the time of visit and advised Licensee to fax it into the department.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2022
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: TEMPLE GARDENS
FACILITY NUMBER: 336425854
VISIT DATE: 05/20/2022
NARRATIVE
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During the tour of the facility LPA and Licensee observed the following deficiencies:
· LPA observed R1 in room 2 which is stated on the facility profile to be a staff room only. LPA requested a copy of the most up to date facility sketch. Licensee was unable to provide one at the time of the visit. LPA will issue a Type B citation for alterations to the facilt without notifying the department.

· LPA observed 2 mop buckets of full of water in the backyard next to the door leading to the backyard. LPA observed R2 ambulating close to the door while speaking with Licensee. LPA will issue a Type B citation for accessible bodies of water.

· LPA observed medications being transferred into pill boxes for all 6 residents. LPA will issue a Type B citation for transferring medication out of its original container.

· LPA was granted entry by S1, this staff had a clearance but was not associated to the facility. Per S1 and Licensee, staff has been working at the facility for a year. LPA will issue a Type A citation and civil penalties in the amount of $500.


An exit interview was conducted, and a copy of this report and appeal rights were provided to staff, Mikita Bonovich on site. An e-mailed copy of this report along with deficiency pages were sent through e-mail to Licensee Esta Hobbs.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022
LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 05/20/2022 12:29 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: TEMPLE GARDENS
FACILITY NUMBER: 336425854

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(2)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above with S1 not being associated to the facility. This poses an immediate safety risk to persons in care.
POC Due Date: 05/20/2022
Plan of Correction
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Licensee will mail in transfer sheet LIC9182 for S1 and associate them to the facility. Licensee will e-mail LPA when photos that this has been done.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4

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: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2022
LIC809 (FAS) - (06/04)
Page: 6 of 8


Document Has Been Signed on 05/20/2022 12:29 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: TEMPLE GARDENS
FACILITY NUMBER: 336425854

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80086(a)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above with Room 2 being designated on the facility profile as a staff room only. LPA observed R1 was living in Room 2. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/30/2022
Plan of Correction
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Licensee will provide LPA an updated facility sketch denoting that Room 2 is a resident room and not a staff room. Licensee will ensure there is approriate mesures taken to finalize this change. Licensee will submit this to LPA by POC date.
Type B
Section Cited
CCR
80088(k)(6)


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 with 6 out of 6 resident's medications being transfered into pill boxes. Per Title 22, medication is not to be transferred out of its original container. This poses a potential health risk to persons in care.
POC Due Date: 05/30/2022
Plan of Correction
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Licensee will submit photo proof of the cabinet where the pill boxes are being kept and e-mail stated that this practice will no longer take place at the faciltity. Licensee will submit proof by POC 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: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2022
LIC809 (FAS) - (06/04)
Page: 7 of 8


Document Has Been Signed on 05/20/2022 12:29 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: TEMPLE GARDENS
FACILITY NUMBER: 336425854

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087


This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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Based on observation, the licensee did not comply with the section cited above with two mop buckets that were filled with water that had not been disposed of and were accessible to residents in the backyard. This poses a potential safety or personal rights risk to persons in care.
POC Due Date: 05/30/2022
Plan of Correction
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Licensee will send a e-mail and photos stating that the water has been removed and that staff have reminded to disposed of stagnant water immediately.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4

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: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2022
LIC809 (FAS) - (06/04)
Page: 8 of 8