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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336427427
Report Date: 03/15/2024
Date Signed: 03/15/2024 11:17:03 AM


Document Has Been Signed on 03/15/2024 11:17 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:NEW HOPE RESIDENTIAL ELDER CARE II LLCFACILITY NUMBER:
336427427
ADMINISTRATOR:MIKENAS, ANNIE JANEFACILITY TYPE:
740
ADDRESS:30221 POWDERHORN LANETELEPHONE:
(951) 467-0330
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY:6CENSUS: 6DATE:
03/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:12 AM
MET WITH:Licensee, Annie Jane MikenasTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola conducted a required annual visit. LPA was greeted and was granted entry and met with Licensee, Jane Mikenas, who was informed of the purpose of the visit. At time of visit there were (6) clients and (3) staff present.

The facility is a one story home with licensed capacity on the first floor with (5) bedrooms and (2) bathrooms. The facility does not have a pool or fire arms. The facility is a residential care facility for the elderly serving elderly ages 60 and above. LPA observed the following:

Infection Control: LPA observed hand hygiene supplies, PPE equipment and cleaning supplies to do regular cleaning of the facility. The facility has a infection control plan on file.

Physical Plant: Physical plant, floors, windows, and doors were observed to be clean and fixtures and furniture were present and in good repair. The facility's outdoor area was observed to be free of hazards. Laundry equipment was observed to be in good working condition. The carbon monoxide detector were operational.

Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required food items.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-233-6759
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2024
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: NEW HOPE RESIDENTIAL ELDER CARE II LLC
FACILITY NUMBER: 336427427
VISIT DATE: 03/15/2024
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Record Review and Resident/Staff Files: LPA reviewed staff files and training along with CPR/First Aid. Client files were reviewed and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: All client medication was locked in a hallway closet. LPA reviewed client medications and found that MARS and medication had discrepancies. LPA observe medication #1 (M1) was not punched but was documented on MARS as given. Medication #2 (M2), and Medication #3 (M3) and Medication #4 (M4) were documented as given, but the medication was still observed in the bubble pack on this date. Medication #5 (M5) indicated to have given for (7) days, had been ordered by the physician to be given for (5) days. Based on staff interviews, medication errors occur and staff are trained every (3) months. The deficiency was cited for medication administration and plan of correction was created.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing last fire drill conducted on 2/2/2024.

An exit interview was conducted where a copy of this report, LIC809-D, LIC811, appeal rights and LIC9098 were reviewed and provided to, Licensee, Jane Mikenas.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-233-6759
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 03/15/2024 11:17 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: NEW HOPE RESIDENTIAL ELDER CARE II LLC
FACILITY NUMBER: 336427427

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
87465 Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility...
(4) The licensee shall assist residents with self-administered medications as needed.
This requirement is not met as evidenced by:


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above with (2) residents which had medication discrepancies for M1, M2, M3, M4, and M5 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/16/2024
Plan of Correction
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By the POC due date, the licensee agreed to send the LPA information on agency were the staff will be cross trained for medication administration. By March 29, the Licensee agreed to have all staff trained and sent LPA proof of this.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-233-6759
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2024
LIC809 (FAS) - (06/04)
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