336427428-4-2-2024-18-AS-JGEE-D3XUGH-20240402153423

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336427428
Report Date: 04/02/2024
Date Signed: 04/02/2024 03:34:30 PM

Document Has Been Signed on 04/02/2024 03:34 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	LOREN'S GOOD LIFE CARE INC		FACILITY NUMBER:	336427428
ADMINISTRATOR:	ELVAIN, LOREN MC		FACILITY TYPE:	740
ADDRESS:	16631 CANYON VIEW DRIVE		TELEPHONE:	(951) 780-6570
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92504
CAPACITY:	6	CENSUS: 4	DATE:	04/02/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:07 PM
MET WITH:	Loren McElvain, Administrator		TIME COMPLETED:	03:45 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) Javina George conducted an unannounced visit to the facility to for the purpose of a 1 year required visit. LPA was greeted and granted entry by Caregiver Jocelyn Esurena, where LPA explained the purpose of today's visit. At the time of the visit was (1) staff and (4) residents present. All staff were observed to have obtained proper fingerprint clearance and were associated to the facility. The facility has an approved hospice waiver for three (3) and there are currently two (2) residents receiving hospice services. Physical plant: LPA conducted a tour of the interior and exterior of the facility. The home is a single story home with five (5) bedrooms and (3) Jack and Jill style bathrooms. LPA observed for the fence in the backyard to be broken with missing slats. Per the Administrator, the fence is in process of being repaired, this was verified by reviewing receipts for materials purchased. The estimated completion date for the fence within the next two weeks. LPA observed inside the kitchen there were missing drawers, exposing the pots and pans in the cabinet below. Per the administrator Loren the drawer is included in the construction and will be completed within the next two weeks. Proof of repairs are to be submitted to the department by 5pm on 4/23/24, as it is contingent upon the weather and wind conditions. The medications are locked cabinets in a secured room/entryway between the facility and the Administrator's home. Additional hazardous chemicals and sharps objects are inaccessible to residents in care. The utilities (gas, water, electric) were observed to be operable. The facility's carbon monoxide and smoke detectors were tested and were observed to be operable. The hot water was tested and measured to be within regulatory limits of 105-107 degrees Fahrenheit. The facility has a mitigation plan on file that was submitted to the department on 4/28/21. The facility has all the required postings, posted on the wall inside the hallway, upon entry to the facility.

SUPERVISOR'S NAME: Tricia Danielson	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 04/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024

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: LOREN'S GOOD LIFE CARE INC	FACILITY NUMBER: 336427428
	VISIT DATE: 04/02/2024

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The facility does have a live in caregiver that resides in room #3.

LPA reviewed two (2) staff and two (2) resident files, the required documentation was present. However for Resident #1 (R1) the physician's report has the last page missing verifying the medical assessment was completed. The administrator contacted R1's responsible party for the complete document.

Based on today's visit no deficiencies were observed, as the needed repairs are already in process.
The administrator agreed to submit the following to the regional office:
-Resubmit the mitigation plan
-Completion of repairs by 4/23/24

An exit interview was conducted and a copy of this report was reviewed and provided to Loren McElvain, Administrator.

SUPERVISOR'S NAME: Tricia Danielson	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 04/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024

LIC809 (FAS) - (06/04)

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