336427429-10-4-2024-18-AS-APEZ-D9QR6B-20241004124427

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336427429
Report Date: 10/04/2024
Date Signed: 10/04/2024 12:44:46 PM

Document Has Been Signed on 10/04/2024 12:44 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:	ST. PEREGRINE'S GUEST HOME		FACILITY NUMBER:	336427429
ADMINISTRATOR/ DIRECTOR:	BAYAUA, JEROME E		FACILITY TYPE:	735
ADDRESS:	29804 ANDROMEDA STREET		TELEPHONE:	8587226448
CITY:	MURRIETA	STATE: CA	ZIP CODE:	92563
CAPACITY: 6		CENSUS: 4	DATE:	10/04/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Jerome Bayaua		TIME VISIT/ INSPECTION COMPLETED:	12:53 PM

NARRATIVE

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Licensing Program Analyst (LPAs), Armando Perez and Ferrer Sabarias made an unannounced visit to the facility for the purpose of conducting a required annual inspection. The LPAs was granted entry by staff to conduct the inspection and met with administrator, Jerome Bayaua. The inspection included the following:

The facility consists of five bedrooms, three bathrooms, a kitchen and dinning area, a living room area, a garage and laundry room, and a patio and yard with sufficient seating and space for activities. There are no bodies of water located on the property. According to Administrator, no weapons are stored in the home. All outdoor and indoor passageways are kept free of obstruction and are free of debris and other trash. The carbon monoxide and smoke detectors were tested and observed to be in operating condition. LPAs observed a fire extinguisher in living room area with an expiration date of July 3, 2025. The home was kept clean and free of any odors.

LPAs began review of client records. Four (4) records were reviewed. LPAs reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. LPAs observed missing Identification records for two clients and an emergency consent form for one client. Administrator will be submitting proof to LPAs of the required forms.

LPAs began review of employee records- Two (2) records were reviewed. LPAs reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and administrator certification with an expiration date 05/17/2024. The administrator provided documentation that confirms payment and submission of the renewal administrator application with the date of 04/25/24.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Armando Perez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2024

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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Document Has Been Signed on 10/11/2024 11:41 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 10/11/2024 09:41 AM

Created By: Armando Perez On 10/04/2024 at 11:48 AM

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
RIVERSIDE ASC, 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: 10/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80072(a)(9)

Personal Rights

(9) To receive or reject medical care, or health-related services, except for minors and other clients for whom a guardian, conservator, or other legal authority has been appointed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	This citation was created in error.
	POC Due Date: 10/11/2024
	Plan of Correction
1 2 3 4	No plan of correction is needed due to being issued erroneously.

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:

Armando Perez

LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2024

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: ST. PEREGRINE'S GUEST HOME	FACILITY NUMBER: 336427429
	VISIT DATE: 10/04/2024

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LPAs observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a locked location for chemicals and sharps in the kitchen.

Medications are centrally stored. There is a locked rolling cabinet allocated for medication storage located in the kitchen area. Centrally stored medication and destruction logs are maintained. Medications reviewed appear to have been dispensed accurately.

P&I was reviewed. LPAs observed that the facility maintains a separate log for each individuals’ monies. Money counted count was accurately reflected on the ledger.

LPAs made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. Smoke detectors and carbon monoxide detectors were tested and found to be operational. The facility is conducting emergency disaster/fire drills monthly; last done on 08/04/2024.

Based on the information received during this visit today in the areas reviewed, there is one deficiency that is being addressed per Title 22, Division 6 of The California Code of Regulations. Administrator will provide proof of completed signed client forms.

An exit interview was conducted, and this report was discussed and provided to administrator, Jerome Bayaua.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Armando Perez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2024

LIC809 (FAS) - (06/04)

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