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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601635
Report Date: 10/16/2023
Date Signed: 10/25/2023 10:55:50 AM


Document Has Been Signed on 10/25/2023 10:55 AM - 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:EMERALD CARE MANORFACILITY NUMBER:
374601635
ADMINISTRATOR:JEROLYN BANDOYFACILITY TYPE:
740
ADDRESS:2605 EMERALD PLACETELEPHONE:
(760) 743-5813
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY:6CENSUS: 5DATE:
10/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Jamie Alido, CaregiverTIME COMPLETED:
05:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jacqueline Shaw Ross made an unannounced visit to the facility to conduct an annual licensing inspection. LPA was met by Jamie Alido, Caregiver, and was granted entry into the facility. LPA spoke with Administrator, James Bandoy by telephone and discussed the purpose of the visit. He authorized Caregiver Alido to conduct the tour and sign off on inspection documents.

A tour of the facility was conducted inside and out. LPA, accompanied by Ms. Alido, conducted a general overall inspection, which included but was not limited to the following: Facility physical plant, food service, medication management, record review and facility administration. The facility is licensed to serve six (6) elderly residents, all of whom may be non-ambulatory. A Hospice waiver is approved for two (2) residents.

The facility is a five (5) bedroom two (2) bathroom one story house. One bedroom is shared two (2) to a room and the other four (4) bedrooms are private.

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 Ms. Alido, 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. Facility fire clearance is maintained in conformity with State Fire Marshal regulations. LPA toured every room in the facility. Resident rooms had the required furnishings and sufficient lighting available. Facility provides each resident with clean linen, in good repair, and sufficient hygiene products for personal use. The hot water temperature measured at 107.9 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. 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. Medications were stored in a locked cabinet. During inspection of medication, LPA observed the following deficiency:
  • Pre-packaged medication (bubble packaged medication) for R1 and R2 were removed from bubble pack and stored in medication pill trays. LPA advised Caregiver that pre-packaged medication must remain in its original container and cannot be transferred from one container to another. Deficiency cited.

This report was discussed with Caregiver Jamie Alido and a copy of this report, LIC809D and Appeal Rights, was provided at the conclusion of the visit.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw RossTELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2023
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 10/25/2023 10:55 AM - 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: EMERALD CARE MANOR
FACILITY NUMBER: 374601635

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2023

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
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Based on LPA observing bubble packed medication for R1 and R2 stored in medication pill trays and not it's original container, the licensee did not comply with the section cited above in [2] out of [5] residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/27/2023
Plan of Correction
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Facility will not transfer pre-packaged medications (bubble packs) from its original container to another container for storage. Facility will also provide a refresher training to staff on proper medication storage and managment. A letter stating review of section cited was conducted by facility. Proof of training will be provided to the Department by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw RossTELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2023
LIC809 (FAS) - (06/04)
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