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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336427428
Report Date: 07/15/2022
Date Signed: 07/15/2022 05:37:18 PM


Document Has Been Signed on 07/15/2022 05:37 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:LOREN'S GOOD LIFE CARE INCFACILITY NUMBER:
336427428
ADMINISTRATOR:ELVAIN, LOREN MCFACILITY TYPE:
740
ADDRESS:16631 CANYON VIEW DRIVETELEPHONE:
(951) 780-6570
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:6CENSUS: 4DATE:
07/15/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Licensee- Loren McElvainTIME COMPLETED:
05:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola, made an unannounced visit to the facility for the purpose of conducting a health and safety check and to gather documentation concerning resident death .LPA met with S1 and S2, who were informed of the purpose of the visit. LPA later met with Licensee Loren McElvain at the facility.

LPA toured the interior and exterior of the facility. LPA toured the resident rooms and observed the residents in care. LPA observed resident medications as well as the facilities food supply, paper supply, and PPE supplies. LPA gathered documentation for concerning R1, LPA collected R1 files, including admissions aggreement, appraisal, physican's report, medication records, and progress notes. Licensee was informed of additional documentation that would be needed to be sent to LPA as soon as possible.

The following health and safety concerns were observed:
  • 7-day non-perishable food supply was not met at the time of visit


An exit interview was conducted where this report was reviewed and provided to licensee, Loren McElvain.

SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2022
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 07/15/2022 05:37 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: LOREN'S GOOD LIFE CARE INC
FACILITY NUMBER: 336427428

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/18/2022
Section Cited

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87555 General Food Service Requirements

(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.
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LPA observed non-perishable food supply at facility which did not meet the reuired one week supply.
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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: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2