371881337-10-10-2023-18-AS-JSRS-CWGV6U-20231010161007

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 371881337
Report Date: 10/10/2023
Date Signed: 10/10/2023 04:10:17 PM

Document Has Been Signed on 10/10/2023 04:10 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:	PARTNERS IN SENIOR LIVING		FACILITY NUMBER:	371881337
ADMINISTRATOR:	TOMLINSON, BRENNA		FACILITY TYPE:	740
ADDRESS:	2657 CRISIE LANE		TELEPHONE:	(858) 261-4639
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92025
CAPACITY:	6	CENSUS: 6	DATE:	10/10/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Brenna Tomlinson, Administrator		TIME COMPLETED:	04:15 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) Jacqueline Shaw Ross made an unannounced visit to the facility for the purpose of an annual review. LPA met with Brenna Tomlinson, Administrator and explained the purpose of the visit. A tour of the facility was conducted inside and out. At the time of visit, there were six (6) residents home and one (1) staff present. The facility is a six (6) bedroom four (4) bathroom one story home. Each resident has a private room. During the tour the following was observed: Residents bedrooms had the required furnishings and were observed to be in good condition. Bathrooms had required hand rails, non-slip mats, hand washing signage and personal toiletries. Night-lights were observed in the hallways. Fixtures and furniture for an operational facility are present and in good repair. All passageways were free of obstructions, charged fire extinguishers and the fire alarm system was operable, medications are kept centralized and locked, hazardous items are kept inaccessible clients. Hot water was tested at 15.7 degrees Fahrenheit. Backyard area is free from obstructions. Kitchen/Food Service: LPA observed the entire kitchen, food is stored properly and dishes are clean and in good condition. There is a sufficient supply of perishable and non-perishable foods. LPA observed fresh fruit and vegetables in the refrigerator. During the inspection of the kitchen and dining area, LPA observed ants and cockroaches in some of the kitchen cabinets and on the dining room floor. Administrator stated the facility has been receiving pest control services specifically for the above mentioned pests since September 2023. LPA was also informed that the facility has been receiving pest control services in general since March of 2022. LPA was provided the last six month copies of invoices from a pest control service. Continue on LIC 809C....

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

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 4

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: PARTNERS IN SENIOR LIVING	FACILITY NUMBER: 371881337
	VISIT DATE: 10/10/2023

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
26
27
28
29
30
31
32

Care & Supervision: Facility has sufficient care staff employed. LPA interviewed one staff member.

Administration: Emergency exiting plans, telephone numbers and Ombudsman information and other required signage are posted throughout the facility. Drills are conducted monthly. The last drill was conducted in August 2023. The Administrator's certificate expires on 9/22/2024.

Record Review and Client/Staff Files: LPA reviewed current staff and all staff have has Criminal Background Clearance, current CPR/First Aid certification, and trainings are current. Upon review of client records, the following deficiency was observed:
-LPA observed three out of six resident resident files reviewed did not have current Physician Reports.

Medication Review: LPA reviewed medication and medication log. Residents' medications are being dispensed according to physician's orders however upon audit of medications the following deficiency was observed:

-LPA observed medications for all clients were prepared in advanced and stored in medication cups. LPA informed Administrator this was against regulations.

Deficiencies were cited in the above references. A copy of this report along with LIC 809D, LIC 811 and Appeals Rights were provided to Administrator Brenna Tomlinson.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 10/10/2023 04:10 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PARTNERS IN SENIOR LIVING	FACILITY NUMBER: 371881337
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(a)

Medical Assessment

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in [3] out of [6] residents which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/24/2023
	Plan of Correction
1 2 3 4	Licensee will contact the families of the residents and hospice agency to obtain current physician reports, will schedule appointments and will send proof that appointents are scheduled and/or completed to the Department by POC due date.

Type B

Section Cited

CCR

87555(b)(27)

General Food Service Requirements

(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/24/2023
	Plan of Correction
1 2 3 4	Licensee will continue to have pest control services and will provide proof of continued services to the Department such as an additional invoice for the following month. Licensee will ensure that staff maintains a clean kitchen, not leave unsealed food on counters and keep gargage cans changed frequently. Licensee will provide refresher training to staff on keeping the facility free from pests. Licensee will send proof of training to the Department 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: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 10/10/2023 04:10 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PARTNERS IN SENIOR LIVING	FACILITY NUMBER: 371881337
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

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 observation, the licensee did not comply with the section cited above in [6] out of [6] persons which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/24/2023
	Plan of Correction
1 2 3 4	Licensee will review regulations and conduct a refresher training to all staff on medication management and storage. Licensee will send proof of training conducted to the Department 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: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

LIC809 (FAS) - (06/04)

Page: 4 of 4