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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426125
Report Date: 09/22/2024
Date Signed: 09/22/2024 02:47:36 PM


Document Has Been Signed on 09/22/2024 02:47 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
, CA 92507



FACILITY NAME:MOTHERLY CAREFACILITY NUMBER:
336426125
ADMINISTRATOR:ARQUISOLA, AUREAFACILITY TYPE:
740
ADDRESS:35496 PRARIE RD.TELEPHONE:
(951) 609-1824
CITY:WILDOMARSTATE: CAZIP CODE:
92595
CAPACITY:3CENSUS: 1DATE:
09/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Licensee/Administrator Aurea ArquisolaTIME COMPLETED:
02:50 PM
NARRATIVE
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On 09/22/2024 at 11:15 AM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Brown met with Licensee/Administrator Aurea Arquisola and was granted entry to the facility. At the time of the visit there was one (1) staff present, and one (1) resident present. LPA Brown explained the purpose of the visit to Licensee/Administrator Arquisola.

The facility is a five (5) bedroom, two (2) bathroom home with a kitchen/dining area, living room/activity room, laundry area and attached two (2) car garage. The facility is Residential Care Facility for the Elderly (RCFE). Facility is Licensed for a capacity of three (3) residents, with a fire clearance for one (1) ambulatory and two (2) non-ambulatory of which one (1) can be bedridden in room #1. Facility has current hospice waiver for three (3). At the time of the visit census was one (1) resident. LPA Brown was accompanied by Licensee/Administrator Arquisola to conduct a general overall inspection, which included, but was not limited to the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). LPA Brown observed no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 76 degrees Fahrenheit. LPA Brown inspected resident bedrooms; they are equipped with required furniture such as: mattresses, lamps, night stands and storage space. LPA Brown observed sufficient lightning. Moreover, LPA Brown observed that bathrooms were clean, and appliances were operating appropriately. LPA Brown observed grab bars and non-skid mat in the resident bathrooms. Hot water temperature was measured in resident’s bathroom and observed 106 degrees Fahrenheit.

In addition, LPA Brown observed bedrooms designated for resident’s use are room #1 and room #2. Bedrooms # 3, #4, and #5 are currently been used by Licensee and family, all adults residing in home have appropriate criminal background clearances and associations to facility. LPA Brown observed an adequate supply of extra linens and towels. ***Continuation in LIC809C ***

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2024
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: MOTHERLY CARE
FACILITY NUMBER: 336426125
VISIT DATE: 09/22/2024
NARRATIVE
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LPA observed a sufficient supply of hygiene items stored for residents use. However, LPA Brown observed no night lights maintained in hallways and passages to nonprivate bathrooms. Deficiency will be issued. Also, LPA Brown observed Resident #1 (R1) has half bed rails. Licensee/Administrator Arquisola reported to LPA Brown that R1 does not have written order from R1 physician indicating the need for half bed rail for mobility. Deficiency will be issued. Moreover, LPA Brown observed sufficient furniture at the facility. To add to that, the facility is equipped with operating combined smoke detectors and carbon monoxide alarms. However, LPA Brown observed no auditory device or other staff alert feature to monitor exits. Deficiency will be issued. Posters such as personal rights, the CCLD complaint poster, Ombudsman Poster and the Emergency Disaster plan were posted in a common area. There was a designated storage space for resident/staff files. There is a cabinet with the resident’s medications locked in the hallway.

Food Service: Seven (7) days non-perishable and two (2) days perishable food supply observed at the facility.

Care & Supervision: The facility has an administrator present in the facility during the visit. However, LPA Brown observed no sufficient number of staff to provide care and supervision to the resident in care as no staff's scheduled to work the night shift, awake and on duty as required for facility with dementia resident. Deficiency will be issued.

Record Review: LPA Brown observed no Infection Control Plan developed by the Licensee at the facility. Deficiency will be issued. LPA reviewed one (1) resident file for admission agreements, updated physician reports, pre-placement appraisal, centrally stored medication list and needs and services plans. LPA Brown observed that Licensee/Administrator Arquinsola did not complete the required Pre-Admission Appraisal for Resident #1 (R1). Deficiency will be issued. LPA Brown observed R1 does not have the required annual medical assessment for resident with dementia. Deficiency will be issued. LPA reviewed two (2) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test results. LPA Brown observed records reviewed were complete.

LPA Brown audited Resident #1 (R1) medications and LPA Brown observed four (4) of R1's medication were not given per R1's physician order. Deficiency will be issued.



An exit interview was conducted where this report (LIC809), LIC809D, LIC9102 and Appeal Rights were discussed and provided to Licensee/Administrator Aurea Arquisola.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/22/2024 02:47 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
, CA 92507


FACILITY NAME: MOTHERLY CARE
FACILITY NUMBER: 336426125

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that four (4) of Resident #1 (R1) medications were given per R1's physician orders which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/23/2024
Plan of Correction
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LIcensee stated to utilize a medication record showing that staff at the facility are giving R1's medications per R1's physician order and Licensee submitted proof to LPA Brown during the visit. Plan of Correction (POC) cleared.
Type A
Section Cited
CCR
87705(c)(4)(A)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident's physical, social, emotional, safety and health care needs as identified in his/her current appraisal. (A) In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal or observation to require awake night supervision.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that there's a staff scheduled to work the night shift, awake and on duty as required for facility with dementia resident which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/23/2024
Plan of Correction
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Licensee submitted an updated Personnel Report (LIC500) indicating that a staff's scheduled to work the night shift as required for facility with dementia resident during the visit. POC cleared.
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: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2024
LIC809 (FAS) - (06/04)
Page: 3 of 9


Document Has Been Signed on 09/22/2024 02:47 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
, CA 92507


FACILITY NAME: MOTHERLY CARE
FACILITY NUMBER: 336426125

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(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
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Based on observation, interview, and record review, the licensee did not comply with the section cited above by not ensuring that Resident #1 (R1) has the required updated/annual medical assessment for resident with dementia which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/23/2024
Plan of Correction
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LIcensee stated to submit R1's medical appointment to complete the required annual medical assessment to LPA Brown on Plan of Correction (POC) due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/22/2024 02:47 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
, CA 92507


FACILITY NAME: MOTHERLY CARE
FACILITY NUMBER: 336426125

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not developing the required Infection Control Plan for the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/01/2024
Plan of Correction
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Licensee stated to submit a copy of the required Infection Control Plan to LPA Brown on Plan of Correction (POC) due date.
Type B
Section Cited
CCR
87307(d)(5)
Personal Accommodations and Services
(5) Night lights shall be maintained in hallways and passages to nonprivate bathrooms.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that night lights were maintained in hallways and passages to nonprivate bathrooms which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/01/2024
Plan of Correction
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LIcensee obtained the required night lights during the visit. POC cleared.
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: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/22/2024 02:47 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
, CA 92507


FACILITY NAME: MOTHERLY CARE
FACILITY NUMBER: 336426125

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87456(a)(2)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not completing the required pre-admission appraisal for Resident #1 (R1) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/01/2024
Plan of Correction
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LIcensee stated to submit Signed Statement of Understanding on CCR 87456(a)(2) to LPA Brown on Plan of Correction (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
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that the facility have the required emergency supplies/kits and emergency food which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/01/2024
Plan of Correction
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Licensee stated to obtain and prepare the required emergency supplies/kits and emergency food and submit proof to LPA Brown on 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: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/22/2024 02:47 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
, CA 92507


FACILITY NAME: MOTHERLY CARE
FACILITY NUMBER: 336426125

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by allowing Resident #1 (R1) to have half bed rail but no written order from R1 physician indicating the need for half bed rail for mobility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/01/2024
Plan of Correction
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Licensee stated to obtain written order from R1 physician indicating the need for half bed rail for mobility and submit a copy to LPA Brown on Plan of Correction (POC) due date. Or, remove the half bed rail and submit proof to LPA Brown on POC due date.
Type B
Section Cited
CCR
87705(j)
Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that the facility has the required auditory device or other staff alert feature to monitor exits which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2024
Plan of Correction
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Licensee stated to install the required auditory device or other staff alert feature to monitor exits and submit proof to LPA Brown on 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: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2024
LIC809 (FAS) - (06/04)
Page: 7 of 9