336426760-9-17-2024-18-AS-SJEN-D97Q3V-20240917114920

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336426760
Report Date: 09/17/2024
Date Signed: 09/17/2024 11:49:33 AM

Document Has Been Signed on 09/17/2024 11:49 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	HACIENDA SENIOR LIVING		FACILITY NUMBER:	336426760
ADMINISTRATOR:	MARLYA DUNHAM		FACILITY TYPE:	740
ADDRESS:	161 N HEMET ST		TELEPHONE:	(951) 927-6817
CITY:	HEMET	STATE: CA	ZIP CODE:	92544
CAPACITY:	66	CENSUS: 23	DATE:	09/17/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Marlya Dunham		TIME COMPLETED:	11:55 AM

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Licensing Program Analysts (LPAs) Seo Jeon and Abdoulaye Zerbo conducted an unannounced annual required visit. Upon entry, LPA was greeted by Marlya Dunham, administrator, and informed her of the purpose of the visit.

Facility Overview: The facility has 2 separate buildings including an office. There are no pools or firearms on the premises.

Infection Control: LPA observed that hygiene and cleaning supplies were available for regular facility maintenance. The facility’s infection control plan was reviewed and found to meet department requirements.

Physical Plant: The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. The outdoor area was free of hazards. Laundry equipment was in good working condition. Sharp and dangerous objects were securely locked and inaccessible to residents. Both the smoke detector and carbon monoxide detector were operational, and the hot water temperature was 110.3°F.

Food Service: The facility’s kitchen was clean and equipped to prepare food. The facility maintained the required two-day supply of perishable foods and a seven-day supply of non-perishable foods.

Care & Supervision/Administration: Adequate staff were present to supervise clients during the visit. The administrator holds a current administrator’s certificate.

Continued on LIC809-C.....

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Seo Jeon	TELEPHONE: 951-248-0309
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024

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: HACIENDA SENIOR LIVING	FACILITY NUMBER: 336426760
	VISIT DATE: 09/17/2024

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Record Review and Resident/Staff Files: LPA reviewed files for five staff members, confirming criminal clearances, updated training, and CPR/First Aid certification. Five resident files were reviewed and contained all required documentation.

Health-Related Services/Incidental Medical Services: All resident medications were securely locked. LPA reviewed medications for three residents, confirming that all medications were listed on the Medication Administration Record (MAR) and accounted for.

Disaster Preparedness: LPA reviewed the facility’s emergency and disaster plan, including documentation of the last fire drill conducted on 6-12-2024, which met department requirements. All facility exits were clear of obstructions.

No deficiencies were cited during the visit. An exit interview was conducted, during which this report was reviewed and provided.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Seo Jeon	TELEPHONE: 951-248-0309
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024

LIC809 (FAS) - (06/04)

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