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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600949
Report Date: 05/22/2024
Date Signed: 05/22/2024 12:22:45 PM


Document Has Been Signed on 05/22/2024 12:22 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:ANNE'S PLACE IIFACILITY NUMBER:
374600949
ADMINISTRATOR:ANNA OSBORNEFACILITY TYPE:
740
ADDRESS:2690 MARY LANE PLACETELEPHONE:
(760) 522-1989
CITY:ESCONDIDOSTATE: CAZIP CODE:
92025
CAPACITY:6CENSUS: 5DATE:
05/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Anna Osborne, AdministratorTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA), Jacqueline Shaw Ross, made an unannounced visit to the facility to conduct an annual inspection. LPA met with Stefan Rudolph, Operations Manager, who was informed of the purpose of the visit. Administrator Anna Osborne and House Manager Dearme Doverte arrived shortly. At the time of visit there were 2 staff and 5 residents present. An overall tour of the facility was conducted inside and out. The facility is licensed for six elderly non-ambulatory residents, and has an approved hospice waiver for four residents. There is approved bedridden fire clearance for one resident. There are currently three residents on hospice. LPA conducted staff and resident interviews.

Tour included:

Physical Plant: The facility is one story with five bedrooms and three bathrooms. The tour of the front entrance, interior and exterior surroundings were observed to be in good repair with no pathway obstruction and facility's water temperature measured at 110 degrees Fahrenheit. LPA inspected all of the residents bedrooms and observed them to be clean, and odor free. The inspection also revealed sufficient lighting and mattress pads in residents bedrooms. Furthermore, smoke and carbon monoxide detectors were also inspected and found to be in working order. All cleaning solutions were observed in a locked secure area. The facility does not house firearms and/or ammunition on grounds. Emergency drills are conducted on a quarterly basis. The last drill was conducted on 4/5/2024. Fire extinguishers were observed to be fully charged.

Food Services: 7 day non-perishable and 2 day of perishable food supply were observed, and all food was properly stored and available to residents.

SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw RossTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024
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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ANNE'S PLACE II
FACILITY NUMBER: 374600949
VISIT DATE: 05/22/2024
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Staff records were reviewed and contained criminal record clearance, 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. Medications were stored in a locked cabinet and were labeled and maintained in compliance with label instructions.

No deficiencies were observed during today's visit. An exit interview was conducted and a copy of this report along with LIC 811 was provided to House Manager Dearme Doverte.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw RossTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024
LIC809 (FAS) - (06/04)
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