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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601310
Report Date: 03/12/2024
Date Signed: 03/12/2024 01:01:41 PM


Document Has Been Signed on 03/12/2024 01:01 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:HIDDEN MEADOWS RESIDENTIAL HOME CAREFACILITY NUMBER:
374601310
ADMINISTRATOR:MONINA ARJONAFACILITY TYPE:
740
ADDRESS:27806 DOGWOOD GLENTELEPHONE:
(760) 751-8575
CITY:ESCONDIDOSTATE: CAZIP CODE:
92026
CAPACITY:6CENSUS: 6DATE:
03/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:53 AM
MET WITH:Monina Arjona, AdministratorTIME COMPLETED:
01:05 PM
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Licensing Program Analyst (LPA) Jacqueline Shaw Ross conducted an unannounced annual visit. LPA met with the Administrator, Monina Arjona and explained the purpose of today’s visit. A tour of the facility was conducted inside and out.

The facility is a (6) bedroom, (3) bathroom one story home.

Tour included:

Physical Plant: The tour of the front entrance, interior and exterior surroundings was observed to be in good repair with no pathway obstruction and facility's water temperature measured above 120 degrees however hot water was adjusted accordingly. LPA observed a warning sign for hot water was posted in each bathroom. LPA inspected each residents room and observed them to be clean, odor free, and furniture in good condition. The inspection also revealed sufficient lighting, bedding and mattress pads in residents’ bedrooms. All furniture throughout the facility was in good condition. 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. Facility does not house firearms and/or ammunition on grounds.

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

Items reviewed/discussed: Staff present have a criminal record clearance in file and are associated to the facility. LPA conducted interviews with staff and residents. Last emergency drill was conducted on 12/1/2023. Facility, staff and residents' records were reviewed and all required documents were present and up to date. All required postings were posted throughout the facility.

SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw RossTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024
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 3


Document Has Been Signed on 03/12/2024 01:01 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: HIDDEN MEADOWS RESIDENTIAL HOME CARE
FACILITY NUMBER: 374601310

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the facility did not keep medication dosage record of residents from January 1, 2024 to present. 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: 03/29/2024
Plan of Correction
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Licensee will ensure medication dosage recording keeping will be updated and maintained on a regular basis. Licensee will provide training to staff on proper record-keeping of medications given and will provide proof of training to the Department by POC date of 3/29/2024.
Type B
Section Cited
CCR
87465(d)(3)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the facility did not keep a record of medication dosage of residents from January 1, 2024 to present. 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: 03/29/2024
Plan of Correction
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Licensee will ensure medication dosage recording keeping will be updated and maintained on a regular basis. Licensee will provide training to staff on proper record-keeping of medications given and will provide proof of training to the Department by POC date of 3/29/2024.
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 HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw RossTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


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: HIDDEN MEADOWS RESIDENTIAL HOME CARE
FACILITY NUMBER: 374601310
VISIT DATE: 03/12/2024
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LPA observed the medications and medications are dispensed according to physicians instructions, however the following deficiencies were observed:

-The facility's record keeping system of medication dosages given to residents was not up to date from January 1, 2024 to present. Deficiency cited.

-The facility's record keeping system of PRN medication dosages given to residents was not up to date from January 1, 2024 to present. Deficiency cited.

An exit interview was conducted with Administrator Arjona Monina and a copy of this report, LIC 809D, LIC 811 and appeal rights were discussed and provided.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw RossTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024
LIC809 (FAS) - (06/04)
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