336427409-8-23-2023-18-AS-JROO-CUYTCX-20230823143727

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336427409
Report Date: 08/23/2023
Date Signed: 08/23/2023 02:37:33 PM

Document Has Been Signed on 08/23/2023 02:37 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	FAMILYCARE HOME - PROSPERITY		FACILITY NUMBER:	336427409
ADMINISTRATOR:	KO, JOSEPH DEXTER		FACILITY TYPE:	740
ADDRESS:	11588 PROSPERITY LANE		TELEPHONE:	(951) 221-1741
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92557
CAPACITY:	4	CENSUS: 4	DATE:	08/23/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Administrator Joseph Ko		TIME COMPLETED:	02:45 PM

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On 8/23/2023, Licensing Program Analyst (LPA) Janette Romero arrived unannounced at the facility to conduct an annual required visit. LPA was greeted and granted entry by Caregiver Gemma Baltazar who was informed of the purpose of visit. During the visit, there was three (3) residents and (2) staff present and LPA was informed that one (1) resident was at day program.

The facility is approved to care for four (4) non-ambulatory residents. LPA toured the facility inside and out. The facility is made up of three (3) client bedrooms, two (2) bathrooms, two (2) living rooms, a kitchen, dining room and garage.

During the visit, LPA observed the following:

Kitchen: LPA observed kitchen area to be clean. Food is stored in a safe and healthful manner. LPA observed the facility had a 2-day supply of perishable foods and 7-day of non-perishable food items. Knives are secured in a locked kitchen drawer.

Dining and Living room: LPA toured the dining room and living/family rooms. LPA observed area to be clean and furniture in good condition. LPA observed residents sitting in the living room watching television.

Detectors: Facility had a fire alarm system. Carbon monoxide and smoke detector were tested and functioning properly.

Continued on LIC809-C.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette Romero	TELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023

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: FAMILYCARE HOME - PROSPERITY	FACILITY NUMBER: 336427409
	VISIT DATE: 08/23/2023

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Centrally Stored Medications: LPA observed a first aid kit with required components. Medications were secured in a kitchen cabinet. LPA reviewed physical medications for two (2) resident as well as Medication Administration Record, no discrepancies discovered.
Bedrooms: Resident bedrooms were each furnished with a bed, chair, closet, clothing storage and lighting.

Bathrooms: Bathrooms have a working toilet, wash basins, and were equipped with a grab bars in the shower. The hot water temperature measured at 110- and 112-degrees Fahrenheit. The facility plenty of clean towels, blankets, and linen, available in different colors for the residents in care.

Laundry/Garage: LPA toured garage. Washing machine and dryer are in good repair and stored in the garage. Emergency food supplies and water are also stored in the garage.

Records: Staff present have a criminal record clearance on file and are associated to the facility. The CPR/First Aid certification for Staff #1 expired on 7/10/2023. Deficiency cited. The facility's last earthquake and fire drill was conducted on 8/5/2023.

Yard/Outside Area: Shaded seating area is available for the residents to sit and relax. . No bodies of water were observed. There were no firearms or ammunition observed at the facility, and LPA was informed the facility will not store firearms or ammunition on the premises.

Residents’ Cash Resources: The facility safeguards residents’ cash resources. LPA reviewed Record of Client’s/Resident’s Safeguarded Cash Resources (LIC 405) for all residents and did not discover any discrepancies.

During today’s visit, LPA observed one (1) deficiency faulting the facility. An exit interview was conducted, and a copy of this report was reviewed and provided to Administrator Ko along with an LIC809-D and Appeals Rights.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette Romero	TELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/23/2023 02:37 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: FAMILYCARE HOME - PROSPERITY	FACILITY NUMBER: 336427409
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(c)(1)

87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. 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 Staff #1 not having a current CPR/First Aid certificate, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/02/2023
	Plan of Correction
1 2 3 4	Licensee agreed to require Staff #1 to obtain a current CPR/First Aid certificate and provide proof of correction to CCLD by close of business on POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Janette Romero	TELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023

LIC809 (FAS) - (06/04)

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