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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426474
Report Date: 08/21/2024
Date Signed: 08/21/2024 01:20:31 PM


Document Has Been Signed on 08/21/2024 01:20 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:DATO GUEST HOMEFACILITY NUMBER:
336426474
ADMINISTRATOR:DATO, CRISTINAFACILITY TYPE:
740
ADDRESS:22836 PORTER ST.TELEPHONE:
(951) 928-0706
CITY:NUEVOSTATE: CAZIP CODE:
92567
CAPACITY:6CENSUS: 5DATE:
08/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Cristina Dato, AdministratorTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA), Stephanie Martinez, conducted a required annual inspection at the facility. The LPA was allowed entrance into the facility and met with Administrator, Cristina Dato. The LPA informed the Administrator of the purpose for the visit. The inspection included the following:

Physical Plant: The facility consists of three (3) resident bedrooms, one (1) staff room, three (3) bathrooms, a kitchen and dinning area, a living room, a laundry room and garage, and a patio and yard with sufficient seating and space for activities. There are no bodies of water located on the property. According to Administrator Dato, 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, bathtub and shower used by residents. Resident showers have non-skid mats present. The carbon monoxide and smoke detectors were tested and observed to be in operating condition. The home was kept exceptionally clean and organized.

Food Service: There is a minimum of 2 days supply of perishable foods and 1 week's supply of non-perishable foods available. Sufficient dinning supplies were available for residents in care. A variety of food was available.

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. There is at least one staff member on the premises with current First Aid and CPR training. Resident records had required documentation; such as admission agreements, medical assessments, and pre-placement appraisals. The medical assessment (physician's report); however, for Resident One (R1) was missing information on the resident's TB test results. Resident Two's (R2's) physician's report was not completely filled out; the report was missing information on the resident's ambulatory status. Resident Four's (R4's) and Resident Five's (R5's) physician's report was missing the TB test information. A citation will be issued. A disaster and mass casualty plan was observed on
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2024
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: DATO GUEST HOME
FACILITY NUMBER: 336426474
VISIT DATE: 08/21/2024
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file. Proof of emergency drills was observed on file. All records were observed to be well organized and safely secured. The inspection found the facility was operating beyond the conditions specified on the license. The facility currently has an approved Hospice Waiver for two (2) residents; however, there are currently four (4) residents in care receiving hospice services. A citation will be issued.

Medication Review: The LPA inspected resident medications. Medications were observed to be well organized, appropriately labeled and inaccessible to unauthorized individuals.

An exit interview was conducted with Administrator Dato in which this report was reviewed and a copy was provided, along with the LIC 811, LIC 9098, and instructions on appeal rights.

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

DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/21/2024 01:20 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: DATO GUEST HOME
FACILITY NUMBER: 336426474

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87204(a)
Limitations -Capacity and Ambulatory Status
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on interview and record review, the licensee did not comply with the section cited above in [4] out of [4] residents receiveing hospice services. This poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 08/21/2024
Plan of Correction
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2
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4
The Administrator provided the LPA with written exception requests for two residents recently receiving hospice services. POC cleared.
Type B
Section Cited
CCR
87458(b)
Medical Assessment
(b) The medical assessment shall include, but not be limited to:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in [1] out of [4] residents who did not have a complete medical assessment on file. The medical assessment for R1 was missing information on the resident's TB test results, R2's report was missing information on their ambulatory status, R4 & R5's report was missing the TB test information. This poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 08/28/2024
Plan of Correction
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The Administrator reported the medical assessment will be completed and proof 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: 08/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2024
LIC809 (FAS) - (06/04)
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