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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426772
Report Date: 03/12/2024
Date Signed: 03/12/2024 02:15:50 PM


Document Has Been Signed on 03/12/2024 02:15 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: 6DATE:
03/12/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Adela Fetalvo, CaregiverTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Yolanda Delgado made an visit to the facility to conduct a case management visit due to an 9099D inadvertently created on December 15, 2021 for a complaint visit and needs to be address during todays visit. LPA met with Adela Fetalvo and explained the reason for the visit. LPA Delgado was granted entry. There are six (6) residents in care and two (2) staff on duty at the time of the visit.

LPA Delgado toured the facility, along with the caregiver and made observations. There are no imminent health and/or safety concerns observed at the time of visit.

LPA Delgado did not observed any health and/or safety hazards inside or outside of the facility at the time of this visit; LPA observed all facility utilities to be on and operating without issue. The LPA assessed the available food supply and observed there was a variety of food types, and the supply exceeds the requirement of a two day supply of perishable foods and a seven day supply of non-perishable foods. The medications were found to be in sufficient supply, locked, and inaccessible to the residents

Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and welfare of the residents in care. For December 15, 2021 visit two (2) deficiencies were observed and civil penalties of $500 were cited at today's visit.

An exit interview was conducted and a copy of this report, LIC 809D, LIC421BG and Appeal Rights was provided to the Caregiver.

SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda DelgadoTELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024
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 2


Document Has Been Signed on 03/12/2024 02:15 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: 03/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/15/2021
Section Cited
HSC
87632(d)(2)

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CRIMINAL RECORD CLEARANCE: All individuals subject to criminal records review...shall prior to working, volunteering...in a licensed facility (1) obtain a California clearance...as required by the Department. This requirement was not being met as evidenced by:
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Administrator states they will not retain staff #6. Administrator will ensure a criminal background clearances and associate to the facility for future employees prior to working at the facility. LPA did not observe staff #6 on premises on 12/15/2021. Civil penalities of $500 dollars will be issued.
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LPA Delgado conducted interviews and records reviewed that 1 of 6 staff member (Staff #6) was not fingerprinted cleared and associated to the facility, which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
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Type B
12/15/2021
Section Cited
CCR87355(e)(1)

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HOSPICE CARE WAIVER: The licensee shally notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or a resident already receiving hospice care services. This requirement was not being met as evidenced by:
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Administrator will submit in writing to CCLD by 12/17/2021 of current residents on Hospice. LPA received Hospice notification for residents on 12/15/2021.
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LPA Delgado observed, interview and review of records revealed that the Administrator did not notify CCLD that 4 of 6 residents were on Hospice in writing within 5 days, which poses an immediate Health, Safety, or Personal Rights risk to person in care.
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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: 03/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2