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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600949
Report Date: 06/13/2024
Date Signed: 06/13/2024 02:38:36 PM


Document Has Been Signed on 06/13/2024 02:38 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:
06/13/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Ana Osborne, LicenseeTIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs), Stephanie Martinez and Valerie Flores, conducted an unannounced visit to the facility to address a violation observed by LPA Martinez. The LPAs met with Ana Osborne, Licensee, and informed her of the purpose for their visit.

LPA Martinez observed an incomplete Resident Appraisal (LIC 603A) on file for Resident One (R1). According to R1's admission agreement the resident was admitted on 05/28/2024. The LPA observed the appraisal to have some information relating to R1's health and physical disabilities; however, the form was not completed. According to Licensee Osborne, a pre-admission appraisal was completed by herself and Staff One (S1) prior to the resident moving into the facility. No additional notes relating to the pre-admission appraisal were observed on file. LPA Martinez was informed by Licensee Osborne that R1, who left the facility for a hospitalization, was observed by staff to have additional needs not reported by the health facility that placed R1. According to Licensee Osborne, no notes documenting the staff observations were completed. Therefore, a citation will be issued.

An exit interview was conducted with House Manager, Dearme Doverte; this report was reviewed, and a copy was provided, along with the LIC 811 and appeal rights.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2024
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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Document Has Been Signed on 06/13/2024 02:38 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: ANNE'S PLACE II
FACILITY NUMBER: 374600949

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/04/2024
Section Cited
CCR
87505

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Documentation and Support: Each facility shall document in writing the findings of the pre-admission appraisal & any reappraisal or assessment which was necessary in accordance w/ Sections 87457 and 87463. If supporting documentation from a physician is required, this input shall also be obtained and may be the same assessment as required in
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The House Manager stated in-service training relating to appraisals will be completed for managerial staff by a third party and proof will be submitted to the Department.
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Section 87458. This requirement was not met as evidenced by: Based on interviews, the Licensee did not ensure findings from R1's pre-admission appraisal were documented. This poses a potential threat to the health, safety and personal rights of the residents in care.
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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: Rikesha StampsTELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2024
LIC809 (FAS) - (06/04)
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