336426750-8-29-2023-18-AS-SMAZ-CV6LAC-20230829083452

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336426750
Report Date: 08/25/2023
Date Signed: 08/29/2023 08:35:22 AM

Document Has Been Signed on 08/29/2023 08:35 AM - 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:	PARTNERS N CARE-CARE HOME		FACILITY NUMBER:	336426750
ADMINISTRATOR:	VAUGHAN, BEVERLEE		FACILITY TYPE:	740
ADDRESS:	5920 COPPERFIELD AVE		TELEPHONE:	(951) 213-6591
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92506
CAPACITY:	6	CENSUS: 6	DATE:	08/25/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:13 PM
MET WITH:	Facility Manager - Karen Vaughn		TIME COMPLETED:	03:53 PM

NARRATIVE

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Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit. LPA was granted entry and met with Facility Manager, Karin Vaughn, who was informed of the purpose of the visit. At the time of the visit there was two (2) staff and four (4) residents present.

The facility is a one story home with (5) bedrooms and (4) bathrooms with attached garage, and pool in the backyard. The residents served are elderly adults 65 years and older. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following:

Infection Control: The LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility.

Physical Plant: LPA observed the resident's bedrooms, bathrooms, and staff office/room. Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. The facility pool was surrounded by a locked gate and there was outdoor furniture and shaded area for residents. Laundry equipment was observed to be in good working condition. LPA observed cleaning chemicals/detergents were accessible to the residents during the visit which does not meet Title 22 regulations and a deficiency will be issued along with a plan of correction. The sharp and dangerous objects were observed to be locked and inaccessible to clients. The smoke detector and carbon monoxide was operational, and the hot water temperature 112F.

Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Sara Martinez	TELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023

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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PARTNERS N CARE-CARE HOME	FACILITY NUMBER: 336426750
	VISIT DATE: 08/25/2023

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Care & Supervision/Administration: Adequate staff are present for the supervision of clients during the visit. LPA also reviewed the staff scheduled showing adequate staff coverage. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The listed administrator possesses a current administrator's certificate.

Record Review and Resident/Staff Files: LPA reviewed three (3) staff files and training. All staff have criminal clearance and updated training along with CPR/First Aid Certification. Three (3) resident files were reviewed and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: Resident medications were locked in a closet near the laundry room. LPA reviewed medications for three (3) residents and found discrepancies with Resident One (R1) and Resident Two (R2) MARs. R1 did not have signatures for medication intake for 08/24, and 08/25. R2 did not have signatures for medication intake from 08/16 - 08/22. A deficiency along with a plan of correction will be issued.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing the facility's last fire and earthquake drill was conducted in May 2023 which met the department requirements. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies in the garage and first aid kit with all required items.

An exit interview was conducted where a copy of this report, deficiency page LIC809-D, LIC811, and appeal rights was provided to Facility Manager Karin Vaughn.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Sara Martinez	TELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/29/2023 08:35 AM - 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: PARTNERS N CARE-CARE HOME	FACILITY NUMBER: 336426750
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. 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 cleaning chemicals and laundry detergent inaccessible to the residents in care which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/01/2023
	Plan of Correction
1 2 3 4	Licensee will agree to train staff on keeping cleaning solutions and other items inaccessible to the residents. Licensee will submit proof of training to CCLD by the agreeed due date 09/01/2023.

Type B

Section Cited

CCR

87465(a)(4)

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 due to the discrepancies for Resident One (R1) and Resident Two (R2) MARs which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/01/2023
	Plan of Correction
1 2 3 4	Licensee agreed to provide staff training regarding dispensing medication and proper documentation of MARs for the residents in care. Proof of correction to be submitted to CCLD by the agreed plan of correction (POC) date 09/01/2023.

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: 08/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023

LIC809 (FAS) - (06/04)

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