336427429-10-12-2023-18-AS-CGOH-CWJU4M-20231012151521

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336427429
Report Date: 10/12/2023
Date Signed: 10/12/2023 03:15:28 PM

Document Has Been Signed on 10/12/2023 03:15 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	ST. PEREGRINE'S GUEST HOME		FACILITY NUMBER:	336427429
ADMINISTRATOR:	BAYAUA, JEROME E		FACILITY TYPE:	735
ADDRESS:	29804 ANDROMEDA STREET		TELEPHONE:	(858) 722-6448
CITY:	MURRIETA	STATE: CA	ZIP CODE:	92563
CAPACITY: 6		CENSUS: 3	DATE:	10/12/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:27 PM
MET WITH:	Caregiver, Joseph Bayau		TIME COMPLETED:	03:15 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) Cheryl Goodrich arrived at 12:27 pm. to conduct an unannounced annual visit. LPA met the Caregiver Joseph Bayaua in the driveway and was granted entry. The purpose of today’s visit is to inspect the facility to ensure that the facility is following California Code of Regulations, Title 22, Division 6. Facility is approved for six (6) ambulatory residents with 3 ambulatory resident in care. Infection Control: The facility has an approved infection control plan and a surplus of supplies for infection control including but not limited to mask, gloves, gowns, first aid kit, and cleaning supplies. Physical Plant and Environmental Safety: The facility temperature read at 73 degrees. The facility consists of 4 resident bedrooms, and 3 bathrooms, living room, kitchen, and backyard. The bedrooms are furnished with tv, lighting, closet space, and dresser. The beds are clean and have clean linens and the pathways are clean and clear of obstruction. The bathroom temperature read at 128 degrees which is outside regulation requirements. The living room and kitchen clean and clear of obstruction. The facility has personal items of the Administrator lined along the walls of each room except the bathrooms and resident’s rooms. The medications are stored in a locked cabinet in the living room and inaccessible to the residents. The facility and has a current fire clearance, smoke and carbon monoxide detectors and fire extinguishers and are in working order. Personnel Records-Training: The staff records are completed with fingerprint clearance, Health screening for TB, CPR/First Aid training, and in-service trainings. Client Records-Incident Reports: The facility has identification and emergency information, physician’s report, resident appraisal, IPP, client rights, and admissions agreement. (Continued on LIC809-C)

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Cheryl Goodrich
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ST. PEREGRINE'S GUEST HOME	FACILITY NUMBER: 336427429
	VISIT DATE: 10/12/2023

NARRATIVE

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(Continued from LIC809)

Client Rights-Information: The facility has client rights information posted in the facility.
Food Service: 7-day non-perishable and 2 day of perishable food supply was observed, and all food was properly stored and available.
Health- Related Services: The facility has a medication logbook, and the facility documents the resident’s medication and is in compliance with physician’s orders and regulations.
Disaster Preparedness: The facility has a disaster plan and has posted the evacuation plan, visible for staff and residents in care. The last fire drill was completed 10/08/23. The facility has emergency supply of food and water.
Items Discussed: The staff left resident unattended for 10 minutes locked in the house. The Administrator has the keys to facility files and spare keys were not left with the staff, and the water temperature read at 128 degrees and staff member was unable to lower the temperature.
Summary: Deficiencies are being cited per Title 22, Div. 6, Chap 8 and listed on LIC 809-D. An exit interview was conducted, Appeal Rights (LIC 9098) along with a copy of this report was provided to Caregiver Joseph Bayaua and his signature on this form confirms receipt of these rights.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Cheryl Goodrich
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/12/2023 03:15 PM - It Cannot Be Edited

Created By: Cheryl Goodrich On 10/12/2023 at 02:53 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ST. PEREGRINE'S GUEST HOME	FACILITY NUMBER: 336427429
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

8507(a)(1)

Responsibility for Providing Care and Supervision This requirement is not met as evidenced by:(1) The licensee shall provide those services identified in the client's needs and services plan as necessary to meet the client's needs.
	Deficient Practice Statement
1 2 3 4	Based on observation upon arrival for the annual inspection the licensee did not comply with the section cited above in 1 out of 1 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/13/2023
	Plan of Correction
1 2 3 4	The staff, Joseph states he will call for assistance if he needs to do anything outside of the facility so that additional staff can monitor the residents in care. The staff states he will continue to monitor the residents in care and will not leave the facility.

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:

Jazmond D Harris

LICENSING EVALUATOR NAME:

Cheryl Goodrich

LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 10/12/2023 03:15 PM - It Cannot Be Edited

Created By: Cheryl Goodrich On 10/12/2023 at 02:58 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ST. PEREGRINE'S GUEST HOME	FACILITY NUMBER: 336427429
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80088(e)(2)

This requirement is not met as evidenced by: Fixtures, Furniture, Equipment, and Supplies. (2) Taps delivering water at 125 degrees F (51.6 degrees C) or above shall be prominently identified by warning signs.
	Deficient Practice Statement
1 2 3 4	Based on observation the bathroom temperature read at 128 degrees and the stat was unable to lower the temperature, the licensee did not comply with the section cited above in 3 out of 3 bathrooms which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/20/2023
	Plan of Correction
1 2 3 4	The staff states he will put a sign up indicating the the temperature exceeded 120 degrees. The staff states he will continue to montitor the temperature.

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:

Jazmond D Harris

LICENSING EVALUATOR NAME:

Cheryl Goodrich

LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 10/12/2023 03:15 PM - It Cannot Be Edited

Created By: Cheryl Goodrich On 10/12/2023 at 03:03 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ST. PEREGRINE'S GUEST HOME	FACILITY NUMBER: 336427429
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1565(f)(2)(D)

This requirement is not met as evidenced by:Other Provisions (D) All facility cabinets and cupboards or files that contain elements of the emergency and disaster plan, including, but not limited to, food supplies and protective shelter supplies.
	Deficient Practice Statement
1 2 3 4	Based on observation the Administrator took the cabinet file keys with him to San Diego and did not provide staff with a copy in his absence, the licensee did not comply with the section cited above in 2 out of 5 cabinets which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/20/2023
	Plan of Correction
1 2 3 4

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:

Jazmond D Harris

LICENSING EVALUATOR NAME:

Cheryl Goodrich

LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

LIC809 (FAS) - (06/04)

Page: 5 of 5