366426413-9-16-2024-56-AS-MMAE-D96UDR-20240916152958

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366426413
Report Date: 09/16/2024
Date Signed: 09/16/2024 03:30:26 PM

Document Has Been Signed on 09/16/2024 03:30 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	APPLE GARDEN SENIORS		FACILITY NUMBER:	366426413
ADMINISTRATOR:	GEORGE KARKALETSIS		FACILITY TYPE:	740
ADDRESS:	12994 RINCON RD.		TELEPHONE:	(760) 240-2600
CITY:	APPLE VALLEY	STATE: CA	ZIP CODE:	92308
CAPACITY:	6	CENSUS: 6	DATE:	09/16/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	George Karkaletsis		TIME COMPLETED:	03:35 PM

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Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required comprehensive annual inspection. LPA met with Administrator, George Karkaletsis, and was granted entry to the facility.

The facility is a Residential Care Facility for Elderly (RCFE) with a license capacity of (6), and a current census of (6). LPA conducted a general inspection of facility, which included, but was not limited to, the following:

Operation/Physical Plant: Indoor and outdoor passageways were kept free of obstruction. The facility has no swimming pools or similar bodies of water. The facility's outdoor activity space is shaded and protected by self-latching gates. The facility is maintained at a comfortable temperature. Resident bedrooms were furnished with beds, night stands, chairs, bed linen and bedroom lighting. Resident bathroom fixtures were operating properly. The hot water temperatures in the bathrooms measured at 107.7 degrees F. The facility is equipped with operating smoke/carbon monoxide alarms, laundry equipment, and telephone service. The facility has posted in a common area: Ombudsman poster, facility license, evacuation plan and emergency telephone numbers. Sharps and cleaning supplies were kept locked and inaccessible to residents in care. The facility's insurance and emergency disaster plan is current.

Food Service: The facility's kitchen area was maintained cleaned. Non-perishable and perishable food supply was sufficient for number of residents in care. The facility’s refrigerator and freezer were operating properly.

Care & Supervision: The facility staff schedule reflects 24 hours a day, 7 days a week staff coverage.

Health Related Services: Resident medications were centrally store in a locked cabinet; however, resident #1 (R1's) and resident #2 (R2's) medications were stored in a weekly pill container and not in their original containers. LPA observed two (2) medications belonging to R1 that were not on their medication list. Deficiencies cited.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024

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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: APPLE GARDEN SENIORS	FACILITY NUMBER: 366426413
	VISIT DATE: 09/16/2024

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Record Review: Resident files were reviewed for admissions agreements, physician’s reports, preplacement appraisals, needs and services plans. LPA observed Resident #3 (R3's) hospice plan does not accurately state the condition of R3's need for hospice services. Staff files reviewed had First Aid/CPR certifications, criminal record clearances, training, and health screenings.

Based on LPA observations and records reviewed, deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted where this report was discussed and a copy with appeal rights was provided to the Administrator at the conclusion of the visit.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/16/2024 03:30 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: APPLE GARDEN SENIORS	FACILITY NUMBER: 366426413
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(5)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observations, the licensee did not comply with the section cited above by maintaining residents medications in a weekly pill container and not in their original containers; which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/17/2024
	Plan of Correction
1 2 3 4	The Licensee/Administrator shall submit a statement of understanding on the regulation cited to the licensing agency by POC due date.

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: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024

LIC809 (FAS) - (06/04)

Page: 3 of 7

Document Has Been Signed on 09/16/2024 03:30 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: APPLE GARDEN SENIORS	FACILITY NUMBER: 366426413
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Incidental Medical and Dental Care Services


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Type B

Section Cited

CCR

87506(a)

Resident Records

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observations, the licensee did not comply with the section cited above by not maintaining a current record of client medications. LPA observed two (2) medications belonging to resident #1 (R1's) that were not recorded on their medication list; which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/17/2024
	Plan of Correction
1 2 3 4	The Licensee/Administrator shall submit a statement of understanding on the regulation cited to the licensing agency by POC due date.

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: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024

LIC809 (FAS) - (06/04)

Page: 4 of 7

Document Has Been Signed on 09/16/2024 03:30 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: APPLE GARDEN SENIORS	FACILITY NUMBER: 366426413
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Hospice Care for Terminally Ill Residents


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Type B

Section Cited

CCR

87633(d)

Hospice Care for Terminally Ill Residents

(d) The licensee shall ensure that the hospice care plan is current, accurately matches the services actually being provided, and that the client's care needs are being met at all times. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observations, the licensee did not comply with the section cited above by not maintaining a current and complete Hospice care plan which includes resident #3 (R3's) conditional need for hospice care on file for review; which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/01/2024
	Plan of Correction
1 2 3 4	The Licensee/Administrator shall submit to the licensing a completed Hospice care plan for R3 by POC due date.

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: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024

LIC809 (FAS) - (06/04)

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