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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426289
Report Date: 04/03/2024
Date Signed: 04/03/2024 06:08:43 PM


Document Has Been Signed on 04/03/2024 06:08 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:CRYSTAL SPRINGS SENIOR CARE FACILITYFACILITY NUMBER:
336426289
ADMINISTRATOR:NUNEZ, NELLYFACILITY TYPE:
740
ADDRESS:41747 WHITTIER AVENUETELEPHONE:
(951) 658-4817
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY:6CENSUS: 5DATE:
04/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:47 PM
MET WITH:Nelly Nunez, AdministratorTIME COMPLETED:
06:10 PM
NARRATIVE
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Licensing Program Analyst (LPA), Stephanie Martinez, conducted a required annual inspection to the facility. The LPA was allowed entrance into the facility and met with Administrator, Nelly Nunez. The LPA informed the Administrator of the purpose for the visit. The facility currently has an approved Hospice Waiver for six (6) residents. The inspection included the following:

Physical Plant: The facility consists of six (6) resident bedrooms, an office, one dinning area, two living spaces, an open kitchen, a laundry area, and a patio with sufficient seating and space for activities. There are no bodies of water located on the property. According to Administrator Nunez, there are no weapons stored in the home. The facility is being maintained at a comfortable temperature. All outdoor and indoor passageways are kept free of obstruction and are free of debris and other trash. There are grab bars for each toilet and shower used by residents. Resident showers have non-skid mats available. The carbon monoxide and smoke devices were tested by the Administrator and were found to be in operating condition. The home was kept free of any odors. The home was exceptionally clean and well organized.

Food Service: There is a minimum of 2 days supply of perishable foods and 1 week's supply of non-perishable foods available. Staff Two (S2), who was observed to be cooking at the time of the LPA's visit, appeared to be following proper hygiene practices. In addition, proof of food handling training was observed on file for S2.

Record Review: All staff were observed to have appropriate fingerprint clearances. LPA did not observe any excluded individuals on the premises at time of visit. Staff responsible for direct care and supervision have current first aid and CPR training. Dementia care training was observed to be conducted for S2. No proof of postural support related training, restricted health conditions related training or hospice related training was observed on file for S2. This posses a potential threat to the health, safety and personal rights of
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024
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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CRYSTAL SPRINGS SENIOR CARE FACILITY
FACILITY NUMBER: 336426289
VISIT DATE: 04/03/2024
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the residents in care. A citation will be issued. The facility was not operating beyond the conditions specified on the license. The LPA was informed by Administrator Nunez there is currently one resident in care who is receiving hospice services. A copy of the resident's Hospice Care Plan was observed to be available. Proof of emergency drill training was observed on file.

Medication Review: The LPA reviewed medications for R1. The LPA observed three of R1's medications to not be listed on the Centrally Stored Medication list retained by the facility. This posses a potential threat to the resident's health and safety. Therefore, a citation will be issued.

An exit interview was conducted with Administrator Nunez in which this report was reviewed and a copy was provided, along with the LIC 811 and instructions on appeals rights.

SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/03/2024 06:08 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: CRYSTAL SPRINGS SENIOR CARE FACILITY
FACILITY NUMBER: 336426289

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

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 in that one out of one staff member, Staff Two (S2), did not have proof of the above required training, which poses a potential health, safety or personal rights risk to persons in care. No proof of postural support related training, restricted health condition related training or hospice related training was observed on file for S2.
POC Due Date: 05/03/2024
Plan of Correction
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The Administrator stated the above required training will be completed and proof will be submited to the Department by the POC due date.
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

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 in that three medications for Resident One (R1) were observed not to be listed on the centrally stored medication sheet, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/10/2024
Plan of Correction
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The Administrator stated an updated centrally stored medication sheet will be completed and a copy will be submitted to the Department 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 StampsTELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024
LIC809 (FAS) - (06/04)
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