374600794-9-2-2022-18-AS-JARA-CHVU9H-20220902152310

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374600794
Report Date: 09/02/2022
Date Signed: 09/02/2022 03:23:29 PM

Document Has Been Signed on 09/02/2022 03:23 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	SUNNYHILL GUEST HOME		FACILITY NUMBER:	374600794
ADMINISTRATOR:	BELLA D. MARGATE		FACILITY TYPE:	740
ADDRESS:	1530 HILLCREST LANE		TELEPHONE:	(760) 723-0985
CITY:	FALLBROOK	STATE: CA	ZIP CODE:	92028
CAPACITY:	6	CENSUS:	DATE:	09/02/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	Staff, Rose De los Santos		TIME COMPLETED:	03:30 PM

NARRATIVE

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Licensing Program Analyst (LPA), Janira Arreola made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA met with staff, Rose De los Santos, who was informed of the purpose of the visit. At the time of visit there was 2 staff and 5 residents present. The facility currently has zero positive or suspected Covid-19 cases.

During today's visit, LPA toured the facility and made observations regarding the infection control measures that the facility has implemented. LPA observed Covid-19 postings at the facility and a single entry point was designated where symptoms screenings and temperature checks occur daily for all visitors, residents, and staff. The facility had an adequate amount of hand hygiene supplies (soap, hand sanitizer, paper towels) in all restrooms. Common areas such as dining rooms and activity rooms have been modified with social distancing and masking policies. There are designated isolation rooms and a plan in place to monitor and attend to those in the isolation rooms. LPA observed a sufficient 30-day supply of PPE equipment. LPA observed facility mitigation plan LIC808 had been approved and submitted to the department.

LPA observed the following technical violations:

LPA review (2) out of (5) resident records and found PCP information had not been updated.
Staff have not been N95 Fit Tested

LPA will document this on LIC9102 TV pages.

LPA along with facility staff noticed the following deficiencies:

Unlocked knifes in kitchen were accessible to resident, as well as unlocked disinfectant in resident restroom.
LPA observed kitchen had a door in the frame with a lock. Facility does not have a current waiver on file for this, per facility administrator Zoraida Margate.
There was no staffing schedule that was provided to LPA at the time of the visit. Therefore, LPA could not verify proper staffing and coverage at the facility.
LPA observed PRN medication in R1's room. Per staff, PRN and vitamins are longer being taken by the resident. LPA reviewed R1's file and found that per physican's report, R1 is not able to store their own medication.

Deficiencies were documented along with Plan of Correction on LIC809-D pages.

An exit interview was conducted, where a copy of this report, along with 809-D pages, LIC9102TV, and appeal rights were reviewed and provided to facility staff, Rose De los Santos.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2022

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 09/02/2022 03:23 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SUNNYHILL GUEST HOME	FACILITY NUMBER: 374600794
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(i)

87465 Incidental Medical and Dental Care (i) Prescription medications ... which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years, which lists the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above with vitamins and PRN medication found in the R1's bedroom. LPA was informed by staff that the resident no longer takes these vitamins and PRN medications. Per R1's file, it was found that R1 cannot stre their own medications. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/03/2022
	Plan of Correction
1 2 3 4	Facility will provide proof to LPA by the POC date of removal of the medication and vitamins in R1's room.

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: Joel Esquivel	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/02/2022 03:23 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SUNNYHILL GUEST HOME	FACILITY NUMBER: 374600794
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87468.1(a)(3)

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above due to a door with lock leading to the facility kitchen. LPA was informed by staff that the door is locked at night and for resident saftey. LPA inquired with Administrator about waiver for this door. LPA was informed there was no waiver on file. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/12/2022
	Plan of Correction
1 2 3 4	Facility will submit waiver request to LPA for use of a locked door leading to the facility kitchen. Facility will need to remove door if this waiver request is denied. This will be provided by POC date.

Type B

Section Cited

CCR

87309(a)

87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above with 3 drawers in the kitchen that had unlocked knifes and other sharp objects such as kitchen shears. LPA observed a key slot on one of the drawers which can be locked, the other (2) appeared to be regular kitchen drawers. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/12/2022
	Plan of Correction
1 2 3 4	Facility will send LPA photo evidence of sharp and dangerous obsjects in a location that is not accessible to residents. This will be provided by POC 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: Joel Esquivel	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/02/2022 03:23 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SUNNYHILL GUEST HOME	FACILITY NUMBER: 374600794
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(e)

87412 Personnel Records (e) In all cases, personnel records shall demonstrate adequate staff coverage necessary for facility operation by documenting the hours actually worked. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above due to there being no staffing schedule provided to LPA for review during the visit. LPA was informed by staff that the staffing schedule is verbal with no documentation. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/12/2022
	Plan of Correction
1 2 3 4	Facility will submit to LPA staffing schedule for the month of September documenting the hours worked for staff. This will show coverage that will provide the proper care and supervision. This will be submitted to LPA by POC 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: Joel Esquivel	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2022

LIC809 (FAS) - (06/04)

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