371881376-2-23-2024-18-AS-JSRS-D2R29W-20240223161236

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 371881376
Report Date: 02/23/2024
Date Signed: 02/23/2024 04:12:46 PM

Document Has Been Signed on 02/23/2024 04:12 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:	ESCONDIDO RETIREMENT GARDEN		FACILITY NUMBER:	371881376
ADMINISTRATOR:	WILLIAMS, MERCELITA		FACILITY TYPE:	740
ADDRESS:	819 N. ROSE STREET		TELEPHONE:	(760) 294-4433
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92027
CAPACITY:	6	CENSUS: 4	DATE:	02/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Mercelita Williams, 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 arrived at the facility unannounced to conduct an annual inspection. LPA was greeted by Mercelita Williams, Administrator, and explained the purpose of the visit. The facility is licensed for age 60 and over, three (3) may be ambulatory and three (3) non-ambulatory, of which one (1) may be bedridden. Bedroom #5 is the only room approved for bedridden. Bedroom #3 and #4 are approved for non-ambulatory. There is a Hospice waiver for 3. The facility is five bedroom two bathroom one-story home. Four bedrooms designated for the residents and two of the bedrooms are shared occupancy. The licensee occupies one bedroom with her husband. There is a kitchen, dining area, and living room, with a 2 car garage. LPA conducted a tour of the home inside and out. During today's inspection, LPA observed the following: Indoor and outdoor passageways were observed to be free from obstruction. There are no pools or bodies of water. Per Administrator, there are no firearms or other dangerous weapons in the facility. Poisons and cleaning agents were observed to be secured and inaccessible to residents in care. Kitchen was observed to be fully operable and clean. LPA toured every room in the facility. Rooms designated as resident rooms had the required furnishings and sufficient lighting available. Licensee provided each resident with clean linen, in good repair, and sufficient hygiene products for personal use. During a tour of the bedrooms the following were observed: -Video cameras were mounted in each of the resident's bedrooms. LPA informed Administrator this is a violation of residents right to privacy. Deficiency Cited. The hot water temperature measured at 119 degrees F. The facility had a functioning carbon monoxide detector, multiple smoke detectors, and multiple operable fire extinguishers. The facility was stocked with a two-day supply of perishable food items and a seven-day supply of nonperishable food items.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024

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

FACILITY NAME: ESCONDIDO RETIREMENT GARDEN	FACILITY NUMBER: 371881376
	VISIT DATE: 02/23/2024

NARRATIVE

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Staff records were reviewed and contained CPR/First Aid training, Health Screening Reports, and annual training. Resident records were reviewed and had a current Physician's Report, Resident Appraisal, Identification and Emergency Information, Admission Agreement, and Centrally Stored Medication and Destruction Records. However during review LPA noticed the following:
-One resident's file was did not have Pre-Appraisal form filled out, only signed. Deficiency cited.

Medications were stored in a locked cabinet and were labeled and maintained in compliance with label instructions. During review of medications LPA observed the following:
-Medications were stored in a medication pill container and not in it's original container. Deficiency cited.

The above deficiencies were cited during today's visit. This report was discussed with the Administrator. A copy of this report, LIC809D, along with Licensee/Appeal Rights, was provided to at the conclusion of the visit.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 02/23/2024 04:12 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: ESCONDIDO RETIREMENT GARDEN	FACILITY NUMBER: 371881376
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/23/2024

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) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/11/2024
	Plan of Correction
1 2 3 4	Administrator will dispense the medication straight from the original container. Administrator will review the regulation and notify the Department by written letter of the understanding of the regulations by the POC date of 3/11/24.

Type B

Section Cited

CCR

87506(b)(15)

Resident Records

(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/11/2024
	Plan of Correction
1 2 3 4	Administrator will ensure that the pre-appraisal form is filled out and will provide the department written proof of the form by the POC date of 3/11/24.

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: 02/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 02/23/2024 04:12 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: ESCONDIDO RETIREMENT GARDEN	FACILITY NUMBER: 371881376
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

2-5800

This requirement is not met as evidenced by: LPA observed video cameras in all of the residents bedrooms.
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in [5] out of [5] persons which poses/posed a potential health, safety or personal rights risk to persons in care...
	POC Due Date: 03/11/2024
	Plan of Correction
1 2 3 4	Administrator removed all video cameras at the time of the visit. Administrator will review regulation cited and will send the Department a written letter of understanding by the POC date of 3/11/24.

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: 02/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024

LIC809 (FAS) - (06/04)

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