336427416-10-20-2022-18-AS-JARA-CKDU3A-20221020151314

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336427416
Report Date: 10/20/2022
Date Signed: 10/20/2022 03:13:27 PM

Document Has Been Signed on 10/20/2022 03:13 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:	A & A FAMILY CARE FOR THE ELDERLY		FACILITY NUMBER:	336427416
ADMINISTRATOR:	ODA, MICHIO ARON		FACILITY TYPE:	740
ADDRESS:	29275 WRANGLER DRIVE		TELEPHONE:	(951) 239-1291
CITY:	MURRIETA	STATE: CA	ZIP CODE:	92563
CAPACITY:	6	CENSUS: 3	DATE:	10/20/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:24 PM
MET WITH:	Admnistrator, Aron Oda		TIME COMPLETED:	03:25 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Janira Arreola, made an unannounced visit on 10/20/2022 at 1:24 p.m. in order to conduct an annual visit with a focus on infection control. LPA met with administrator Aron Oda, who was informed of the purpose of the visit. At the time of the visit there were (3) staff and (3) residents present. LPA proceed to conduct a walk through of the facility's interior and exterior. LPA observed there was a central entry point where screenings are conducted for facility visits. LPA observed COVID-19 postings throughout the facility. The facility has a 30-day supply of PPE equipment that is readily accessible for residents staff. The facility has a designated visitation area in the facility. LPA observed the resident bedrooms that would be used as isolation rooms. The resident bathrooms were observed to be clean and have the appropriate hand hygiene supplies such as hand sanitizer, soap, running water and paper towels. The facility has a cleaning plan in place to disinfect and clean the high touch surfaces of the facility and the isolation rooms. The staff have leave in case of contact or testing positive for COVID-19. The staff have been trained on how to properly don and doff the PPE equipment, and there is a plan of care in place to attend to those residents that would be in the isolation rooms. LPA was able to review the facility's infection control plan that had been submitted to the regional office for review. LPA was informed by administrator that the staff have not yet been FIT tested for the N95 respirator. LPA will document this on a advisory note and send administrator information on where to get his done. LPA requested the monkey pox infection control plan and was informed by administrator that they have not yet made one for the facility. LPA will document this on an advisory note and send the administrator information on how to have this completed. LPA found (2) chairs in the shaded area of the yard that had ripped fabric showing stuffing inside the cushions. LPA took pictures of these chairs. LPA will issue a technical advisory note for chair covers. CONTINUED ON LIC809-C*

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022

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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Document Has Been Signed on 10/20/2022 03:13 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: A & A FAMILY CARE FOR THE ELDERLY	FACILITY NUMBER: 336427416
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(5)

“87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.” This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above with residents medication that is being transfered between containers into day pill boxes. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/31/2022
	Plan of Correction
1 2 3 4	Licensee shall send LPA pictures of the medication cabinet showing that the pill boxes will no longer be used.

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) 202-5067
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022

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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: A & A FAMILY CARE FOR THE ELDERLY	FACILITY NUMBER: 336427416
	VISIT DATE: 10/20/2022

NARRATIVE

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LPA found that the backyard exit path way was blocked by children's toys that belong to the licensee's children. This is a potential risk for the residents in care. LPA will document this on an advisory note.

LPA also found (3) pill boxes being used for the residents medication by the day. This is a potential risk to residents in care. This will document on an LIC 809-D page along with plan of correction.

An exit interview was conducted where this report along with LIC809-D page, and appeal rights were reviewed and provided to administrator, Aron Oda

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022

LIC809 (FAS) - (06/04)

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