336425952-9-25-2023-18-AS-SMAZ-CVZUGZ-20230925153509

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336425952
Report Date: 09/25/2023
Date Signed: 09/25/2023 03:35:18 PM

Document Has Been Signed on 09/25/2023 03:35 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	MARCELINE'S HOME CARE		FACILITY NUMBER:	336425952
ADMINISTRATOR:	SANGIAN, MARCELINE & JAN		FACILITY TYPE:	740
ADDRESS:	136 GARCIA DR.		TELEPHONE:	(951) 665-3045
CITY:	SAN JACINTO	STATE: CA	ZIP CODE:	92582
CAPACITY:	6	CENSUS: 3	DATE:	09/25/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:41 PM
MET WITH:	Jan Sangian - Administrator		TIME COMPLETED:	03:47 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) Sara Martinez conducted an unannounced annual required visit. LPA was granted entry and met with Administrator, Jan Sangian, who was informed of the purpose of the visit. At the time of the visit there was two (2) staff and three (3) residents present. LPA toured the exterior and interior of the facility. The facility has no bodies of water, firearms, or ammunition. The facility has charged fire extinguishers, operating smoke alarms, and carbon monoxide detectors. Outdoor and indoor passageways were kept free of obstruction. The facility's backyard had shaded area for seating. LPA observed a kitchen drawer containing knives and sharp objects not locked and accessible residents during the tour. This poses a potential health & safety risk to the residents in care, a deficiency will be issued along with a plan of correction. LPA toured the kitchen. Food was stored in a safe and healthful manner. The facility had a 2 day supply of perishable food items and 7 day supply of nonperishable food items. LPA toured the resident bedrooms. LPA observed the resident's bedrooms, bathrooms, and staff office. Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair and were present. The bathrooms were operating in safe and sanitary conditions and contained grab bars and nonskid mats. The hot water temperature measured 116 F. The facility had a complete first aid kit and emergency supplies. LPA reviewed staff and resident files. Staff files had the required documentation including a health screening report and current first aid/CPR certification. Resident files had the required documentation including an admission's agreement and updated physician's reports. LPA reviewed medications. Medications were dispensed appropriately according to the physician's orders. The facility was not able to provide the Infection Control Plan or Mitigation Plan to LPA during the visit. This poses a potential health & safety risk to the residents in care, a deficiency will be issued along with a plan of correction.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Sara Martinez	TELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2023

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

Document Has Been Signed on 09/25/2023 03:35 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MARCELINE'S HOME CARE	FACILITY NUMBER: 336425952
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87208(a)(12)

Plan of Operation

(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: (12) The Infection Control Plan pursuant to Section 87470. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in having the Infection Control Plan available at the time of the visit which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/02/2023
	Plan of Correction
1 2 3 4	Licensee will submit a completed Infection Control Plan to LPA by the agreed plan of correction date.

Type B

Section Cited

CCR

87705(f)(1)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in having multiple knives and sharp objects in the kitchen drawer unlocked and accessible to residents which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/02/2023
	Plan of Correction
1 2 3 4	Licensee will submit proof of a drawer with a lock for the knives and sharp objects so they will be inaccessible to residents. Licensee will submit proof of drawer with a lock by the agreed plan of correction 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 Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Sara Martinez	TELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MARCELINE'S HOME CARE	FACILITY NUMBER: 336425952
	VISIT DATE: 09/25/2023

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

LPA observed the exiting doors leading outside the facility had a door alarm (auditory device) attached and LPA observed the door alarm was not in operating condition for the backdoor, front door, and garage door. This poses a potential health & safety risk to the residents in care with dementia, a deficiency will be issued along with a plan of correction.

LPA reviewed the facility's emergency and disaster plan. LPA inquired about the facility's last fire and earthquake drill and administrator stated they have a fire drill once a year which does not meet department requirements. Regulations for residents with dementia states a fire and earthquake drill shall be conducted every three months. This poses a potential health & safety risk to the residents in care, a deficiency will be issued along with a plan of correction.

An exit interview was conducted where a copy of this report LIC809, the deficiency page LIC 809-D, and appeal rights where provided to Administrator Jan Sangian.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Sara Martinez	TELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 09/25/2023 03:35 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MARCELINE'S HOME CARE	FACILITY NUMBER: 336425952
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(j)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in having operational door alarm devices for the exit doors for the garage and back door which poses/posed a potential health,safety, or personal rights risk to persons in care.
	POC Due Date: 10/02/2023
	Plan of Correction
1 2 3 4	Licensee will review the regulation Care of Persons with Dementia 87705 and submit a statement that the licensee has read and trained staff on the regulation. Licensee will submit proof of exit door alarms being operational by the agreed plan of correction date.

Type B

Section Cited

CCR

87705(l)(8)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in conducting a fire and earthquake drill every three months when having residents with dementia admitted which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/02/2023
	Plan of Correction
1 2 3 4	Licensee will submit a signed statement that a fire and earthquake drill was conducted with the time and date indicated on the statement. Licensee will submit proof of correction by the agreed 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: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Sara Martinez	TELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2023

LIC809 (FAS) - (06/04)

Page: 4 of 4