336427416-9-13-2024-18-AS-JARA-D93P3C-20240913105719

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336427416
Report Date: 09/13/2024
Date Signed: 09/13/2024 10:57:35 AM

Document Has Been Signed on 09/13/2024 10:57 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:	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: 5	DATE:	09/13/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Administrator, Aron Oda		TIME COMPLETED:	11:05 AM

NARRATIVE

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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit. LPA was granted entry and met with Administrator, Aron Oda, who was informed of the purpose of the visit. At the time of the visit there was two () 3staff and five (5) residents present.

The facility is a two story home, three (3) bedrooms and one (1) bathroom downstairs are designated for residents on the first floor. No pool or firearms are present.

Infection Control: LPA observed hygiene supplies, PPE equipment, and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements. LPA reviewed staff records and found that all staff had infection control training.

Physical Plant: Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards with outdoor furniture and shaded area for residents. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to the residents. The smoke detector and carbon monoxide was operational, and the hot water temperature 105.2F.

SUPERVISOR'S NAME: Tricia Danielson	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-233-6759
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024

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: A & A FAMILY CARE FOR THE ELDERLY	FACILITY NUMBER: 336427416
	VISIT DATE: 09/13/2024

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Care & Supervision/Administration: Adequate staff are present for the supervision of residents during the visit. LPA also reviewed the staff scheduled showing adequate staff coverage. The listed administrator, possesses a current administrator's certificate. The facility liability insurance policy was out of date, the licensee agreed to have this renewed and submitted to LPA. Deficiency was cited. Technical note was documented for the licensee to send the grant deed to the LPA by September 27, 2024.

Record Review and Resident/Staff Files: LPA reviewed three (3) staff files and training. All staff have criminal clearance and updated training along with CPR/First Aid Certification. Three (3) resident files were reviewed. One (1) resident who did not have an updated LIC602, the licensee coordinated with the resident's responsible party during the visit and established a date when the resident would see their primary care physician. (1) resident did not have a signed Needs and services plan. Deficiency was cited for the resident to have an updated file. One (1) resident is currently receiving home health services, who did not have a plan of care from the home health agency on file, but does have a plan of care with the facility. Technical note was documented and the licensee agreed to send this plan of care to the LPA by September 27, 2024.

Health Related Services/ Incidental Medical Services: All resident medication was locked in a kitchen cabinet. LPA reviewed medications for three (3) residents and found all medication listed on MARS and all required labeling was found to be in place.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing the facility's last fire and earthquake drill was on 07/20/2024 which met the department requirements. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies in the garage and first aid kit with all required items.

An exit interview was conducted where a copy of this report was provided to Administrator Aron Oda.

SUPERVISOR'S NAME: Tricia Danielson	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-233-6759
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/13/2024 10:57 AM - 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 ASC, 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: 09/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.605

Other Provisions

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above with liability insurance policy that expired Auguts of 2022 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/04/2024
	Plan of Correction
1 2 3 4	The licensee agreed to renew their policy for liability insurance and send proof of a current policy by the 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: Tricia Danielson	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-233-6759
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/13/2024 10:57 AM - 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 ASC, 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: 09/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87467(a)(3)

Resident Participation in Decisionmaking

(a) Prior to, or within two weeks of the resident's admission, the licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility. (3) The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident's condition, or once every 12 months, whichever occurs first. Significant changes shall include, but not be limited to occurrences specified in Section 87463, Reappraisals. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above with LIC602 that was not within a year for the resident and Needs and Services plan that was not reviewed with the resident's responsible party. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/27/2024
	Plan of Correction
1 2 3 4	The licensee was able to coordinate with the resident's responsible party during the visit. The client has a set appointment to meet with the primary care provider. The licensee agreed to update the needs and services plan and review with the responsible party and have them sign the plan. Proof of the LIC602 and needs and services plan will be submitted by the POC due date.

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: Tricia Danielson	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-233-6759
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024

LIC809 (FAS) - (06/04)

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