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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426772
Report Date: 05/02/2022
Date Signed: 05/02/2022 02:00:09 PM


Document Has Been Signed on 05/02/2022 02:00 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
RIVERSIDE, CA 92507



FACILITY NAME:AILIDA RETIREMENT HOMEFACILITY NUMBER:
336426772
ADMINISTRATOR:ANNALISA OLIVAN-BLANCAFLORFACILITY TYPE:
740
ADDRESS:38124 AUGUSTA DRIVETELEPHONE:
(951) 696-2482
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY:6CENSUS: 5DATE:
05/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Annalisa Olivan-BlancaFlorTIME COMPLETED:
02:12 PM
NARRATIVE
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Licensing Program Analyst (LPA) Yolanda Delgado made an unannounced visit to the facility to conduct an annual inspection with an emphasis on infection control. LPA arrived at 10:10 AM, LPA was met by Caregiver Socorro Malit and explained the purpose of the visit. Present in the facility during time of visit were one (1) staff as well as five (5) residents. Administrator Annalisa Olivan-Blancaflor arrived during the inspection There are currently no cases of COVID-19 within the facility.

During today's visit, LPA toured the facility and made observations pertaining to the facility's infection control measures. LPA observed incomplete signage throughout the facility, sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and proper use of face coverings by staff. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, additional PPE supplies need to be maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the proper use and disposal of PPE and overall infection control needs to be improved. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and residents for COVID-19, when and how to isolate/quarantine residents, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas. The facility has a limited plan in place to monitor resident(s) regularly for any changes in condition and to subsequently notify the resident(s) physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses.

Based on the observations made during today’s visit, four (4) deficiencies were cited per Title 22, Division 6, of the California Code or Regulations. An exit interview to review this report was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda DelgadoTELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 05/02/2022 02:00 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
RIVERSIDE, CA 92507


FACILITY NAME: AILIDA RETIREMENT HOME
FACILITY NUMBER: 336426772

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2022

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
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Based on LPA's observation during inspection the door to the laundry room and door to the garage was propped with a 5-gallon water jug, inside the garage were disinfectants and cleaning solutions., the licensee did not comply with the section cited above. Administrator failed to make sure doors were locked and secured This poses an immediate health and safety risk to residents in care.
POC Due Date: 05/09/2022
Plan of Correction
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Licensee to agree to conduct and submit In-service for all staff on securing and locking up disinfectants and cleaning solutions inaccessible for clients while working in the facility. Proof to be submitted to the Department by 5pm on POC.
Type B
Section Cited
CCR
87468.2(a)
Additional Personal Rights of Residents in Privately Operated Facilities
(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation and record review, the licensee did not comply with the section cited above licensee did not ensure COVID-19 Infection Control measures: COVID-19 screening protocols and practices for all staff, residents and visitors. The personal rights of persons in care to safe and healthful to the health, welfare, and safety of persons in care, as required by the CA Dept. of Public Health Guidance.
POC Due Date: 05/09/2022
Plan of Correction
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The licensee will obtain additional PPE supplies, comply with COVID-19 screening protocols and practice. Proof of correction will be submitted to licensing by 5pm on POC.

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: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda DelgadoTELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 05/02/2022 02:00 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
RIVERSIDE, CA 92507


FACILITY NAME: AILIDA RETIREMENT HOME
FACILITY NUMBER: 336426772

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
81087(a)
Buildings and Grounds: (a) The Facility shall be clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation Facility failed to meet the safety and well-being of all staff as the refrigerator door handle is broken and injury can occur while in use. LPA observed the caregiver went to open the refrigerator door handle and the handle is broken and the licensee did not ensure that the refrigerator was safe and good repair and this poses an immediate, safety and personal rights risks to staff and persons in care.
POC Due Date: 05/09/2022
Plan of Correction
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Licensee to agrees to replace refrigerator. Proof to be submitted to the Department by 5pm on POC.
Type B
Section Cited
CCR
87468.2(a)(1)
Additional Personal Rights in Privately Operated Facilities

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation of Resident room #C, there was a camera inside a flower vase and the monitor for the camera was located inside the kitchen on top of a card table. The licensee did not ensure the personal privacy of the residents and this poses an immediate, safety and personal rights risks to persons in care.
POC Due Date: 05/09/2022
Plan of Correction
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Licensee to read CCR 87468.2 in its entirety and will remove any and all cameras from residents’ room(s). Proof to be submitted to the Department by 5pm on POC.

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: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda DelgadoTELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3